Body typing intake form What's your full name? Please let me know the best email address to contact you through Are you How tall are you? What's your date of birth? What time were you born? What city & country were you born in? Please select any symptoms you're currently experiencing from the list below Acne Addison Disease ADHD/ADD Anxiety Bladder infections Body Odour Brain fog Brittle Nails Bruising easily Candida Celiac Disease Chronic fatigue Consistent Cold & Flu symptoms Constipation Cracked Heels Cramping (body) Cramping (Menstrual) Crohn’s Disease Cushings disease Cysts Dandruff Dark Eye circles Dehydration Depression Diabetes Diarrhea Difficulty concentrating Digestive issues Dizziness Dry eyes Dry hair Dry mouth Dry skin Ear ringing (Tinnitus) Eating disorder Eczema Endometriosis Enlarged prostate Erectile disfunction Eye Floaters Fatigue Fevers Fibroids Food intolerance and allergies (List below details) Frequent urination Fungal infections (List below where) Gastrointestinal Issues Graves Disease Hair loss (advise if postpartum in comments below) Hashimoto’s thyroiditis Headaches Heart Burn/Indigestion Heart palpitations, changes in normal heart rate, or heart pain Hirsutism HIV/AIDS Hypo/hyperadrenal symptoms Hypo/hyperthyroid symptoms Inflammation Insomnia Interstitial Cystitis Intolerant to cold Intolerant to heat Irritability Joint pain (List below where) Kidney dysfunction Lipedema Liver dysfunction Loss of appetite Low Libido Lupus Lymphedema Memory loss Menopause Mood Swings Multiple sclerosis Muscle pain and weakness Night sweats No Periods Numbness/tingling sensation in limbs Panful Periods Panic Attacks PCOS Perimenopause Poor sleep Premature aging Premature Ejaculation Psoriasis Rapid Weight gain Rapid Weight loss Raynaud’s syndrome Rheumatoid arthritis Scleroderma Short/Long Periods (List details below) Sinus infections Skin rashes (List below where on the body) Slow healing of cuts and scrapes Slow muscle recovery after activity STD’s (List details below) Swollen and tender lymph nodes Symptoms of or diagnosis of fibromyalgia Symptoms of or diagnosis of Lyme disease Tinea Toxic shock symptoms Ulcerative Colitis Vertigo Vision decline Yeast infections Please list any symptoms not listed above that you're currently experiencing Please select any symptoms you have experienced in the past, but no longer do, from the list below Acne Addison Disease ADHD/ADD Anxiety Bladder infections Body Odour Brain fog Brittle Nails Bruising easily Candida Celiac Disease Chronic fatigue Consistent Cold & Flu symptoms Constipation Cracked Heels Cramping (body) Cramping (Menstrual) Crohn’s Disease Cushings disease Cysts Dandruff Dark Eye circles Dehydration Depression Diabetes Diarrhea Difficulty concentrating Digestive issues Dizziness Dry eyes Dry hair Dry mouth Dry skin Ear ringing (Tinnitus) Eating disorder Eczema Endometriosis Enlarged prostate Erectile disfunction Eye Floaters Fatigue Fevers Fibroids Food intolerance and allergies (List below details) Frequent urination Fungal infections (List below where) Gastrointestinal Issues Graves Disease Hair loss (advise if postpartum in comments below) Hashimoto’s thyroiditis Headaches Heart Burn/Indigestion Heart palpitations, changes in normal heart rate, or heart pain Hirsutism HIV/AIDS Hypo/hyperadrenal symptoms Hypo/hyperthyroid symptoms Inflammation Insomnia Interstitial Cystitis Intolerant to cold Intolerant to heat Irritability Joint pain (List below where) Kidney dysfunction Lipedema Liver dysfunction Loss of appetite Low Libido Lupus Lymphedema Memory loss Menopause Mood Swings Multiple sclerosis Muscle pain and weakness Night sweats No Periods Numbness/tingling sensation in limbs Panful Periods Panic Attacks PCOS Perimenopause Poor sleep Premature aging Premature Ejaculation Psoriasis Rapid Weight gain Rapid Weight loss Raynaud’s syndrome Rheumatoid arthritis Scleroderma Short/Long Periods (List details below) Sinus infections Skin rashes (List below where on the body) Slow healing of cuts and scrapes Slow muscle recovery after activity STD’s (List details below) Swollen and tender lymph nodes Symptoms of or diagnosis of fibromyalgia Symptoms of or diagnosis of Lyme disease Tinea Toxic shock symptoms Ulcerative Colitis Vertigo Vision decline Yeast infections Please list any symptoms not listed above that you have experienced in the past, but no longer do Share details about any pain points. (physical or emotional) Any areas you're struggling with (how you see yourself, cravings, movement restrictions, unmotivated, etc) and how long you have had them Have you ever had any Covid-19 Vaccinations No Yes - 1 Yes - 2 Yes - 3 Yes - 4 or more Have you ever had any childhood, adult or travel vaccinations? No Yes If yes, please list vaccinations recieved and the year the last one was below. (e.g. Childhood Vaccination Schedule - 1999, Travel Vaccinations for Africa - 2003, Annual Flu Vaccinations between 2015 - 2020) Please list any pharmacetical medications you're currently taking Please list any supplements you're currently taking Please upload an image of yourself front facing Please upload an image of yourself side facing Please upload an image of yourself rear facing Please share any images from your past (as an adult) of a time when you felt healthy or didnt expereince any symptoms. (you can upload multiple here) What would you consider your main food craving Rich & Spicy Food Greasy, Salty Food Sweets or Starches Diary Products How would you best describe your energy pattern daily Good in the morning, better in the evening I have good energy all day, but am worn out by the evening Up and down all day I am a morning person Submit
