Consultation Questionnaire

Consultation questionnaire
KRISTINA HOLEY + JUSTINE WENGER

Please complete the form below prior to your consultation.

Name *

Email *

Where are you located? *

Date of birth *

Weight *

Height *

What are the main goals/changes you would like to see in your skin? *

What are the main goals/changes you like to see in your overall health? *

Skin: Current AM/PM regimen; including all products (skin care + makeup) and brands, in order of use - please also explain if you like the product and how your skin feels after use: *

Skin: Do you enjoy your current AM/PM regimen? *

Skin: Do you wear sunscreen? Brand/SPF *

Skin: Describe the condition of your skin - Please be as specific as possible: What does your skin look and feel like in the AM? *

Dietary: Typical Diet - Be as specific as possible, including the hours of the day you typically eat these foods. Please also list fats that you cook with and any foods you snack on throughout the day: *

Dietary: Do you experience signs of irregular blood sugar such as hypoglycemia, feel dizzy when you stand up, or extremely fatigued? How is your energy throughout the day? Do you experience any gas/nausea/bloating after eating sweet foods, even natural sugars ex. fruit? *

Dietary: What is your appetite like? When are you the most hungry - morning, afternoon, evening? Do you experience cravings? What is your biggest meal of the day? Are there any foods/food groups you avoid or limit and why? *

Dietary: On average how much water do you drink each day? Other beverages you consume regularly? *

Dietary: Do you drink caffeine? If so, when and how much: *

Dietary: Supplements/Vitamins: What do you take, when, and what quantities (include brands): *

Dietary: Do you take any over-the-counter drugs or prescription medications? If so, please list: *

Dietary: In the past, have you taken a lot of antibiotics, as a child or young adult? *

Dietary: Do you have any known allergies? *

Dietary: Do you smoke? How many cigarettes per day? *

Digestion: Do experience any frequent digestive symptoms - bloating, gas, abdominal pain, heartburn/acid reflux? Do you notice if it’s triggered by certain foods? *

Digestion: How regular are your bowel movements? Do you frequently experience constipation or loose stool (or both/alternating)? Have you observed any abnormalities in your stool - undigested foods, color changes, stool that floats, particularly foul smell? *

Digestion: Do you experience frequent headaches? If so, how often and when during the day? Do you frequently take pain medications? *

Sleep: How many hours of sleep do you get on an average night? What time do you generally go to bed and wake up? *

Sleep: Do you have any issues with sleep - hard to fall asleep, waking up often (at what time/s), waking too early in the morning, hard time falling back asleep? Please explain: *

Sleep: Are you rested when you wake up? How is your overall energy and at what time of the day do you generally feel your best? *

Exercise: Is your lifestyle active? *

Exercise: Do you exercise regularly? If so, what kind/s and how often? *

Exercise: What does your skin look like after exercise? If you are flushed, where is most of the redness- on the cheeks or lower portion of the face? How long until it subsides? *

Exercise: Do you sweat easily? *

Aside from physical activity, does your overall body temperature generally run warm or cool? What type of temperature or season do you most prefer? *

Do you often feel thirsty? *

Do you experience night sweats? Do you flush easily? *

Do you experience cold hands/feet regularly? *

Hormonal: How many days is your total cycle? Does it vary month to month? *

Hormonal: How many days do you bleed? Would you describe your flow as light or heavy? Any clots? *

Hormonal: Do you experience any PMS symptoms (breakouts, cravings, bloating, mood swings, breast tenderness)?If so, at what part during your cycle do you experience these symptoms? *

Hormonal: How does your skin fluctuate throughout your cycle? *

Hormonal: Do you take Birth Control or any other birth control methods (ex. IUD, ring, etc.)? Have you ever in the past- if so, when and what type, for what duration? *

Do you have low libido? *

Have you had any pregnancies or births? How many and when? *

Are you trying to conceive? *

Medical: When did you last see a primary physician? *

Medical: Have you had any recent blood work? What were the results? *

Medical: Please list any medical conditions you have and the date/s of diagnosis: *

Medical: Have any members in your immediate family been diagnosed with any health conditions, please list: *

Lifestyle: Travel: How often? *

Lifestyle: Please rate your level of stress, currently, and in the past: *

Lifestyle: What helps you relieve stress? *

Thank you! Anything else you would like to discuss or any questions you have for us?

Food Journal Analysis

Please download our 5 Day Food Journal Outline. Please be as honest and as specific as possible. It’s most effective if it truly reflects how you naturally eat throughout an average week (versus trying to eat a certain way or only recording “good days”). It will be helpful to see what foods/meals you gravitate towards in your lifestyle, what you like to eat, food combinations, timing of food intake, etc.. Try to record at the end of each day so it can be as accurate as possible. If you have any questions before getting started, let us know.

Consultation questionnaire KRISTINA HOLEY + JUSTINE WENGER

Food Journal Analysis

Consultation questionnaire
KRISTINA HOLEY + JUSTINE WENGER