what is your ethnic background
Family History of Alzheimer's or dementia:
Family history of other major health conditions? (heart disease, degenerative disease, cancer, mental illness):
recent weight gain or loss?
Do you have a primary care physician?
how often do you see him/her?
when was the last time you had a full panel of lab work done?
Current medical diagnoses:
Current herbs/nutritional supplements
How would you describe your general mood?
Do you periodically or Often experience depression?
Which of these descriptions describe your current memory issues or areas of concerns?
Check all that apply:
What are your regular exercise habits?
Do you like weight/strength training?
do you like group fitness classes?
Are you vegetarian, vegan, pescatarian, or a carnivore?
How many meals do you eat per day and what time?
What food groups do they generally consist of?
Do you snack? If so, What Are Your Usual “Go-To” Snacks?
Do you crave sugar/sweets/carbs/fats? If so, what do you indulge in and how often?
Do you have any gluten, dairy or any other food sensitivities or allergies?
Have you ever had a food allergy test?
Do you regularly drink soda or juice? If So, Which, How Much and How Often?
General alcohol consumption habits:
General coffee consumption habits:
How would you describe your digestion?
Do you experience regular bowel movements?
Do you experience frequent heartburn?
Do you experience bloating after meals?
How much water do you drink each day and from what source?
On Average, How Many Hours Of Sleep Each Night Do You Get?
What time do you generally go to sleep and wake up?
What is the quality of your sleep?
How do you generally feel upon waking? (physically/mentally/emotionally)
How do you generally feel when you go to bed? (physically/mentally/emotionally)
Do you ever wake up in the night? If so, how often? Do you have trouble getting back to sleep?
How is your energy throughout the day?
Do you currently or have you ever had a meditation practice?
Are you familiar with breathwork practices
do you pray or have any other spiritual practices?
how much time do you spend in nature?
how much time do you spend in sunlight
How many hours of screen time (TV, Computer, Phone, and Tablet) do you average a day?
What are your favorite self-care practices that you do regularly?
List some things you enjoy engaging in:
What is your stress level on a scale of 1-10?
On A Scale Of 1-10 (1=Not, 10=Very), How Satisfied Are You In These Areas Of Your Life:
Diet
Spiritual Connection/practice
