Your Wellness Biography – Your Labwork – Natural thyroid and hormone treatment

Name*
First Last
Email*
Phone*
Arthritis
Self Parent Grandparent Sibling
Allergies/sinus
Self Parent Grandparent Sibling
Cancer/Type
Self Parent Grandparent Sibling
Diabetes
Self Parent Grandparent Sibling
Heart disease
Self Parent Grandparent Sibling
Thyroid disorder
Self Parent Grandparent Sibling
Other
Self Parent Grandparent Sibling
Gastro disease
Self Parent Grandparent Sibling
Women
Last Pap
Mammogram
Menses
DEXA
Colonoscopy
Hysterectomy
- Yes
- No
Men
Last Digital Rectal Exam - Prostate health
Colonoscopy
Drug or Food Allergies
Please list all current prescription medications, over the counter meds, herbs and dietary supplements you take:
Medication/ Supplements Dosage Purpose How long have you taken it Side Effects
To what extent are you open and willing to make changes in your lifestyle and diet?
- Not Open to Change
- Somewhat Open to Change
- Very Open to Change
Context of Care Review
What is your expectation of Integrative Health?
Whom or What helps you daily?
What is holding you back?
What do you love to do?

Women