Before consult form | Body & Mind reset

First name

Last name

Email

Phone

Birthday

Dia

Mês

Ano

Address

Please list any major medical problems you have had, such as asthma, hypertension, stroke:

Please list any surgeries you have had:

Are you allergic to any medications or supplements:

Please list other physicians or other professionals participating in your care:

Please list any medications you take regularly with dose and frequency (include birth control pills and over-the-counter medications):

Please list any herbs or nutritional supplements you take:

Please list any diseases or conditions in your family:

Select all that applies. My stool 💩 is:

Separate hard lumps, like nuts – hard to pas

Sausage-shaped but lumpy

Like a sausage but with cracks on the surface (normal)

Like a smooth, soft sausage or snake

Soft blobs with clear-cut edges

Fluffy pieces, mushy (mild diarrhea)

Watery, no solid pieces

Appetite

I feel hungry 1-2 hours after I eat

I feel hungry 3-4 hours after I eat

I feel hungry 5-6 hours after I eat

I’m “never” hungry

Do you notice any strong food cravings?

Dry, crunchy, or salty foods

Spicy or sour foods

Sweet or creamy foods

I don’t have cravings

How easily do you fall asleep?

Hard to fall asleep—mind is too active

Fall asleep easily but wake up during the night

Fall asleep quickly and sleep deeply

How do you feel when you wake up?

Restless or anxious

Warm or slightly irritable

Groggy or slow

I wake up happy and energized

What’s your bedtime?

What’s your rising time?

Do you exercise? How many times a week and for how long? What activities do you usually do?How do you feel afterwards?

Describe your typical breakfast:

Describe your typical lunch:

Typical Dinner:

Typical Snacks:

Do You Drink Alcohol ? (If so, what form and how much / how often?

How much water do you consume on daily basis, do you prefer cold, iced, room temperature?

Do you drink soda or fruit juices? (If so, what form and how much / how often?

Do You Take Caffeine (If so, what form and how much / how often?

Do you smoke or use drugs?

The body and mind method