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Missy DeWitt
Please read carefully and fill out the form below prior to your session. Click submit once finished.
Name
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First Name
Last Name
Email
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Phone
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Reason for visit/goals/concerns (prioritized):
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How many ounces of water/day?
What other beverages and how much?
TextDo you use artificial sweeteners? If so, which ones? How often and in what?
Do you eat breakfast? If so, what?
How much of the following do you consume? (example: 1D = 1/day, 2W = 2/week, 3M = 3/month)
Fresh fruit. Raw vegetables, Fermented foods , Fast foods , Meat , Eggs, Dairy
What do you crave?
TWhat is the first thing you do when you get up in the morning?
What time do you eat your first meal? Last meal?
Which meal is your largest of the day?
Describe a typical largest meal.
Do you exercise/move/participate in fun sweaty activity? If so, what and how often?
Do you look forward to it? How do you feel when you are finished?
What time do you go to bed? How long do you sleep? Do you wake often? If so, why and at what time(s)?
Do you feel rested when you wake up for the day?
Do you have pain when you first get up? If so, where? Does it go away upon moving?
Do you have daily bowel eliminations? If yes, how many per day? If no, please describe your elimination pattern.
Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided below this form.
BSC # and color
Are you post-menopausal? If yes, at what age did you enter menopause? What were the characteristics of your menopausal experience?
Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?
Are you now, or in the near future, planning to become pregnant?
Is your menstrual cycle regular: Longer than 28 days? Shorter? Is your flow longer or shorter than 5 days?
Do you have cramps or clotting? Would you describe the color of your menses as bright red, dark purple, or brown?
Do you experience PMS, cyclical headaches, or cravings?
Do you take any supplements? If so, what, how often and why? Do you take any OTC medications routinely (such pain reliever or allergy medicine)? If so, what and how often? Do you take prescription medications (prescribed by a licensed medical professional?) If so, what and how often?
Please make specific lists below listing what category it falls under.
Have you had any surgeries? If so, what and when?
Have you received any diagnoses from licensed medical professionals? If so, what and when?
On a daily basis, would you say it is easy to notice how you are feeling? Use a numerical scale with 10 being difficult and 1 easy.
Do you have a therapist that supports you with your emotional /mental health?
Have you struggled with depression in the past or currently?
Do you feel as if a life experience or trauma in your life has affected your overall wellbeing? Yes or No, and explain on if you feel comfortable doing so.
Do you have regular rituals for self care? If so, give a short list:
Rate your stress level 1 being minimal 10 being maximum.
Anything else you wish to share or I should know?
Please check all with which you are familiar::
homeopathy
Bach flowers
emotion code
muscle testing
essential oils
raindrop technique
Have you ever been in consultation with a naturopath? If so, why? How long ago?
What was suggested? Did you experience a good outcome? What did you like about it? What wasn’t as successful for you?
Do you have regular adjustments with a chiropractor?
Do you have regular body work/massages?
I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease. Please place your electronic signature below:
Thank you!
Bristol Stool Chart
