Discovery Form Home / Discovery Form Complete a Discovery Form Before we meet, I’ll ask you to fill in this short, confidential form. It helps me understand your symptoms, history, and health goals so that our first contact is meaningful. First NameLast NameDate of BirthGenderSelect GenderMaleFemalePhone NumberEmail Address *Street AddressCityState/ProvinceZIP / Postal CodeMain ConcernsWhat brings you to seek help today? (tick all that apply)Difficulty with focus, memory, or attentionLow energy or fatigueGut/digestive problems (bloating, IBS, food sensitivities)Hormonal issues (PMS, menopause, thyroid, testosterone, etc.)Mood concerns (anxiety, depression, irritability)Skin problems (eczema, acne, rashes)Hearing, tinnitus, or balance concernsOtherOtherWhat are your main health concerns right now?0 / 180When did these symptoms start?0 / 180What makes the symptoms better or worsed?0 / 180Medical HistoryCurrent diagnoses:0 / 180Current medications:0 / 180Current supplements that you are taking:0 / 180Past surgeries or hospitalizations:0 / 180Lifestyle SnapshotTypical diet:0 / 180Allergies/intolerances:0 / 180How many hours of sleep do you get on average?Sleep quality:GoodPoorExercise:RegularRarelyNeverWhat kind of exercise?0 / 180Daily stress level:HighModerateLowFamily HistoryAny history of chronic illness in your family (e.g. diabetes, heart disease, dementia, autoimmune conditions)?0 / 180Your GoalsWhat do you hope to achieve by working together?0 / 180Are there specific changes you’d like to see in your health or daily life?More energy and vitalityBetter focus and mental clarityFewer gut issuesBalanced hormonesClearer skinWeight managementOtherOtherConsentConsent *I confirm that the information I provided is correct to the best of my knowledge and understand this form is confidential. Submit
