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Pre-Consultation Assessment

Holistic Health & Lifestyle Questionnaire

This comprehensive assessment helps me understand your complete health picture through an ancestral lens — from nourishment and movement to sleep, stress, and your connection to natural rhythms. Please take your time answering thoughtfully.

All responses are confidential and stored securely

Personal Details

SECTION 1 – Your Health Goals

SECTION 2 – Medical History

SECTION 3 – Family History

SECTION 4 – Daily Energy

SECTION 5 – Sleep

SECTION 6 – Sunlight & Circadian Health

SECTION 7 – Physical Activity

SECTION 8 – Stress & Emotional Wellbeing

SECTION 9 – Digestion

Reference — Bristol Stool Scale:

Bristol Stool Scale chart showing 7 types of stool consistency from hard lumps (Type 1) to watery (Type 7)
Type 1: Separate hard lumps
Type 2: Lumpy & sausage-like
Type 3: Cracked sausage shape
Type 4: Smooth & soft
Type 5: Soft blobs, clear edges
Type 6: Mushy, ragged edges
Type 7: Watery, no solids

SECTION 10 – Eating Habits

SECTION 11 – Typical Daily Food Intake

SECTION 12 – Food Frequency

FoodDailyWeeklyMonthlyNever
Grass-fed beef
Lamb
Chicken
Eggs
Fish
Shellfish
Organ meats
Bone broth
Raw dairy (where legal and appropriate)
Fermented foods
Fruit
Vegetables
Honey
Prepackaged / ultra-processed foods
Soft drinks
Alcohol
Seed oils (fried foods, commercial snacks)

SECTION 13 – Hydration

SECTION 14 – Cravings

SECTION 15 – Women's Health (if applicable)

SECTION 16 – Men's Health (if applicable)

SECTION 17 – Environmental & Lifestyle Factors

SECTION 18 – Community & Purpose

SECTION 19 – Readiness for Change

A Note on the Ancestral Approach

An ancestral approach understands health through interconnected pillars — food quality, sleep, circadian rhythms, movement, sunlight, stress, relationships, environment, and daily habits — rather than focusing on diet alone. This questionnaire supports wellness coaching and nutritional education. It is not a diagnostic or medical assessment. Any symptoms, ongoing health concerns, or suspected medical conditions are best discussed with your trusted healthcare professional.

This form is confidential and will only be used to prepare for your consultation. Take your time — thorough answers help me serve you better.