Health History

Bio-Individual Background Info Form

Read this before you start!
The more info you fill out, the more rich our Discovery Session and subsequent Strategy Session will be. Feel free to expand and explain a LOT. I read the form without judgement so as you are filling it in, replace any self-judgement with curiosity.

If you are filling this out over time, save your longer answers to a document as the website will NOT save them if you close or restart your computer.

Once you hit submit you will see the page with the 5 Day Tracking Tool. That's how you'll know the submission was successful. Contact [email protected] if you have any issues or want to follow up to make sure I received it.

All the information you share in this form and during sessions is confidential between you and me. If there is anything you'd rather speak about than write down, note that in the form. If you have any questions about what a question is asking, email me at [email protected].

Five Cent Functional Nutrition Program Includes the Following:
Step 1: Submit this form
Step 2: Sharon will send a follow up email with more clarifying questions
Step 3: Complete a consecutive 5 day Food and Symptom Tracker in your own time and submit it to Sharon
Step 4: Sharon will send a follow up email with more questions and ideas specific to your health journey
Step 5: Send Sharon Five Cents and Feel Better as you are on your way to living as your most Vibrant Self (venmo: @Sharon-Cav PayPal: [email protected])

Client Info

* Indicates required field

Name *

First

Last

Is this for yourself or someone else? *

Phone Number with Country Code *

Skype Name *

Email *

Birth Country *

Occupation *

How'd you find me? *

Relationship Status *

Living Situation *

Statistics

Date of Birth *

Age *

Weight (lbs) *

Birth Order and Ages of Siblings *

Weight One Year Ago *

Children's Ages (if any) *

Height *

Ideal Weight *

Gender *

Birth Weight (if known) *

History

Have you ever traveled or lived outside your birth country? If so, where and when? *

How much time have you had to take off from school or work in the last year due to illness? *

0 - 2 Days 3 - 7 Days 8 - 14 Days More than 15 Days

Have you or your family experienced any life changes? If so, please explain. *

Have you experienced any major losses in life? If so, please explain. *

Health Concerns

What are you main health concerns? Describe in detail including severity of symptoms. Include both diagnosed and undiagnosed conditions. *

When did you first experience each of these concerns? *

How often did you take antibiotics in childhood? *

How often did you take antibiotics as a teen? *

List any medicines you are currently taking and for what purpose. *

Please list the date and description of any surgical procedures (including oral and cosmetic) *

How have you dealt with each of these concerns so far and what success have you experienced, if any? *

Have any of your family members experienced similar issues? Please explain who. *

When have you taken antibiotics as an adult? *

List any supplements, vitamins, herbs, minerals you are currently taking and for what purpose. *

What health practioners are you currently seeing? *

Nutrition Practices

Describe your diet at the onset of your health concerns that you listed at the top of this form. *

Are there any foods you avoid because of the way they make you feel? If yes, name them and the symptoms. *

Do you have symptoms immediately after eating like bloating, gas, sneezing, or hives? Please explain. *

Are you aware of any delayed symptoms after eating such as fatigue, muscle aches, sinus congestion, etc.? *

What percentage of your meals are homecooked? *

Are you currently following a special diet? Please explain *

Are there foods you crave? Please list them. *

Do you have any know food ALLERGIES? *

Do you have any known food SENSITIVITIES? *

Is there anything else you want to share about your current diet, history, or relationship to food ("picky" eating, bulimia, anorexia, etc.)? *

Intestinal Status

Medical Status

Health Hazards

Have you ever been exposed to chemicals or toxic metals (lead, mercury, arsenic, aluminum, copper)? *

Have you been exposed to second-hand smoke? Please explain *

Do odors affect you? Please explain. *

Do you smoke? How often? *

Oral Health History

When was your last dentist visit and what was the reason for the visit? *

What is your current dental and oral regimen? Please note how often and what kind of toothpaste you use. *

Do you have any mercury amalgams? If no, were they removed? How? *

Do you have any concerns about your oral and dental health or anything else you want to share? *

Lifestyle Stressors

Have you had periods of eating junk food, binge eating, or binge dieting? List any diet that you were on for a period of time. *

How often are you stressed? Is it acute or chronic or both? How does your mood or behavior change when you are stressed? *

Have you used or abused alcohol, drugs, pharmaceuticals, tobacco, or caffeine? Do you still? Please tell me more. *

Sleep

How satisfied are you with your sleep? What could be better about it? *

Are you asleep between 2 and 4 am? *

Do you fall asleep in less than 30 minutes? *

Do you stay awake all day without dozing? *

Do you sleep between 6 and 8 hours per night? *

Sexual History

Do you have any concerns with your sexual functioning (pain during intercourse, dryness, libido, erectile dysfunction, etc.)? *

How many sexual partners have you had in the past year? Have they been men, women, or both? *

Females Only

How old were you when you first got your period? *

Describe your symptoms during your menstruating years. PMS, painful periods, irregular periods, spotting between periods, etc.? *

Have you taken/do you take birth control? If so, please list the length of time and type. *

Have you experienced yeast infections or UTIs? Are they regular? *

Have you had any problems with conception or pregnancy? *

Are you taking hormone replacement or therapy or hormonal supportive herbs? If yes, please explain. *

Mental Health Status

How are your moods in general? Do you experience more anxiety, anger, or depression than you would like? *

Describe your usual energy level on a scale of 1-10 (1 = lowest, 10 = highest) *

At what point in your life did you feel best? Why? What did it/does it feel like? *

More important bits...almost finished!

Do you feel your friends and family will be supportive of you making health and lifestyle changes to improve your quality of life? If no, explain. *

Who in your family or health care team will be most supportive of you making diet and lifestyle changes to improve your health? *

Is there ANYTHING else that may be helpful in addressing your health concerns? List even the littlest things. Sit right now and close your eyes and note all the pains, irritations, sensations you feel in your body. Anything worth noting? *

By checking the box below and typing my name, I agree to the Terms of Service.

I Agree *

Yes

Full Name (Electronic Signature) *

Save all your long answers to another document before clicking submit just in case the connection goes out or it doesn't process correctly.

Once you hit submit you will see the page with the 5 Day Tracking Tool. That's how you'll know the submission was successful. Contact [email protected] if you have any issues.

What are your health goals and aspirations? Make them specific and measurable? On a scale of 1 to 10, how are you doing on these goals? *

Though it may seem odd, consider why you want to achieve these goals for yourself. Explain. *

I am interested in working with people who are ready to receive support on their individualized journey to health and healing. I'm trained to uncover and unlock the mysteries of what is holding you back from optimum health and happiness. Together we will create a partnership to help you understand what is going on and how to take steps with confidence to heal yourself! On a scale of 0 - 10, how committed are you to doing everything it takes to feeling your most happy, healthy, vibrant self? (0 = Not at all. I'd rather keep feeling this way until I find a magic pill. 10 = I believe in myself and this system and I am 100% ready to heal) *