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8110 Blanding Boulevard
Jacksonville, FL, 32244
(904) 379-4621
Health for the BOLD
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Home
CHIROPRACTIC
FITNESS
NUTRITION
SAUNA THERAPY
RESOURCES
Contact
Name
*
First Name
Last Name
Email
*
Gender
*
Male
Female
Date of Birth
*
Current Weight
*
Ideal Weight
Height
*
Primary Health Concern
*
What are your top 3 health goals?
*
Do you consider yourself muscular and/or athletic?
*
Yes
No
List any supplements you are currently taking
*
List any medications you are currently taking
*
List any accidents, injuries, or traumas that you have experienced
*
List all doctor diagnosed medical conditions you have, even if they are currently under control
*
List any non-food allergies or sensitivities
*
List any symptoms you are currently experiencing
*
How many hours of sleep per night are you getting on average during the week
*
Do you have trouble falling asleep or staying asleep
*
Yes
No
Rate your willingness to change
1 = Not Willing, 5 = Very Willing
1
2
3
4
5
Are you doing any time-restricted eating
*
Yes
No
How much water do you drink in a day?
*
How much caffeine do you drink in a day?
*
Do you drink alcohol?
*
Yes
No
Do you experience any of the following
Diarrhea
Constipation
Both on and off
Bloating
Heartburn/Reflux
Belching
Stomach Pain/Cramping
Blood in stool
Undigested food in stool
Do you have any food sensitivities or food allergies?
*
Yes
No
Have you had any significant fluctuations in weight
*
Yes
No
Do you experience any of the following
Foggy thinking
Memory problems
Trouble concentrating
Do you have high cholesterol?
*
Yes
No
I don't know
Are you on a statin
*
Yes
No
Was your gallbladder removed?
*
Yes
No
Do you experience any of the following
Eczema
Rash
Acne
Psoriasis
Other skin issues
Do you experience any of the following
Headaches
Fibromyalgia
Muscle pain
Osteoporosis
Migraines
Joint pain
Rheumatoid arthritis
Low energy
High Stress
Have you been exposed to (or think you have been exposed to) mold
*
Yes
No
Do you have any amalgam (silver) fillings
*
Yes
No
Have you been exposed to Lyme disease
*
Yes
No
Do you follow a specific diet?
*
No
Core plan
Advanced plan
Paleo/Carnivore
Keto
Whole 30
SIBO/FODMAP
Plant based
Other
How many days per week are you exercising (heart rate elevated, breathing heavy, sweating)
Is your job active, lightly active, inactive?
Active
Lightly Active
Inactive
Do you experience low sex drive?
Yes
No
MALES ONLY - Do you experience any of the following
Erectile Dysfunction
Low sex drive
Low testosterone
Waking up in the middle of the night to use the restroom
Issues with prostate or PSA
Loss of hair on calf muscles
Gynecomastia
Difficulty building muscle
Hair loss or thinning hair
Infertility
FEMALES ONLY - Do you experience any of the following
Vaginal dryness
Low sex drive
High estrogen
Irregular cycles
Heavy cycles/clotting
Painful cycles/cramping
PCOS
Incontinence (with laughing, coughing, sneezing, running, jumping)
Facial hair
Hair loss or thinning hair
Hysterectomy
Early menopause
Infertility
Are you taking hormone replacement therapy
*
Yes
No
Please list any other important details about your health symptoms that were not captured in the above questions.
Thank you!
