Medical and Personal History Medical & Personal history Please provide as much detail as you can.Talk soon, Kelli RD Name * First Name Last Name Email * Phone (###) ### #### Date of Birth * Mailing Address (for labs) * Current medical conditions * PCOS Thyroid Condition IBS Diabetes, Pre-Diabetes or Insulin Resistance Autoimmune Condition Psychiatric Condition such as Anxiety, Depression, PTSD Other Please list all prescription medications you are currently taking, including dosage and frequency. * Please list all vitamins, minerals, herbs, or over-the-counter supplements you currently take. * Menstrual & Reproductive History (if applicable) Taking a birth control Current cycle length is 25-40 days Cycles are irregular PMS symptoms occur (bloating, pain, insomnia, heavy bleeding) Using Fertility Awareness Method Please explain your digestive health and bowel frequency * Please explain your sleep routines and regularity (bonus points if you track HRV and can include this) * Please check all that apply in regards to weight and body composition * I regularly track my weight I own or have access to a body composition scale I have weight cycled a lot throughout my life I prefer to take a body neutral approach and not focus on weight Have you done any lab work in the last 12 months? If yes, please add to our shared folder! What other healthcare providers and healers have you worked with in the past? Who are you currently still seeing? Thank you!
