Health Questionnaire

Name

Phone

Email

Address

Gender

Female

Male

Birthday

Birth place and exact time of day (if known)

I already have an appointment booked with Dr Marie

Yes

No

I'm booked:

I wish to...

My main reason(s) for reaching out:

Telling more about myself and why I'm here:

History of birth, upbringing, wellness/illness, injury:

If you were born with vaginal birth or caesarean section, please note.

This is going on in my physical body:

This is my mental state:

This is going on emotionally in my life:

My energy level is:

If it's fluctuating during the day, please describe futher.

This is my soulful connections in life:

For example, is there faith, meaningfulness and community?

Quality of life:

Quality of sleep:

Quality of relationships/social connections:

Balance in mood:

How much of my lifestyle is on a routine:

Quantity of sleep per night:

Please note how you feel after sleep.

Quantity of meditation/mindfulness/yoga per week:

Please note how you feel after meditation.

Quantity of exercise (and type) per week:

Please note how you feel after exercise.

Eating habits:

Elaborate eating habits:

Please include any food allergies/reactions.

Eating effects on my body, mind and energy:

Note stool consistency and when/how often you visit the bathroom

I would also like to tell you...

Health QuestionnaireWelcome to Dr Marie Gershagen