Please provide a fake name, so that your data remains anonymous.
1. What is your fake name? (Using a fake name will provide maximum privacy... just don't forget what it is!) *This question is required.
2. When is your upcoming appointment with Anne at BuzzNutrition?
3. Health Goal #1: Please tell me your primary Health Goal.
4. What, if anything, seems to support Health Goal #1?
5. What seems to work against Health Goal #1 and/or make the problem worse?
6. Health Goal #2: Please tell me your second Health Goal. (Or leave blank if you don't have one.)
7. What, if anything, seems to support Health Goal #2?
8. What seems to work against Health Goal #2 and/or make the problem worse?
9. Health Goal #3: Please tell me your third Health Goal (or leave blank).
10. What, if anything, seems to support Health Goal #3?
11. What seems to work against Health Goal #3 and/or make the problem worse?
12. Please list the supplements you're currently taking. If you feel like including brand, dosage & timing, that'd be helpful, but don't take the time if that seems tedious or annoying. We could just talk about it later.
13. Please list the medications you're currently taking. Same deal as above: dosage & timing would help unless you don't feel like typing it all out.
14. Medication history: Have you ever taken antibiotics? Please check all that apply.
15. Medication history: Have you ever been prescribed cortical steroids, like hydrocortisone?
16. Have you ever been diagnosed with a medical condition? If so, please list each condition along with the general month/year of diagnosis.
17. Have you ever had surgery? If so, please list each condition along with the general month/year of the surgery.
18. Beyond illness & surgery mentioned above, have you experienced any significantly stressful life events? If so, please list each chronologically, including the year and month, if possible. Label with a 1-2 word description, or just call it "Event 1" if you'd rather not specify.
19. Do you smoke cigarettes?
20. Please describe your exercise/movement habits (type of exercise, how many times per week). How does it make you feel (exhausted/invigorated/annoyed)?
21. How would you describe your diet? (Check all that apply.)
22. Are you allergic to any foods? (do they cause hives, difficulty breathing, anaphylactic shock)
23. Do you have an intolerance or sensitivity to any foods? (Cause a wider array of symptoms & are not life-threatening like an allergy.)
24. How many times per day to you eat?
25. What happens if you skip a meal?
26. On an average day, how do you feel before you eat?
27. On an average day, how do you feel after you eat?
28. If you have cravings, what are they (ex. sweet, salty, chocolate, etc) and when do they occur (ex. first thing in the morning, 2 hours after a meal, around bed time, etc)?
29. Please describe a typical first meal or snack, including what time you eat.
30. Please describe a typical second meal or snack, including what time you eat it.
31. Please describe a typical third meal or snack, including what time you eat it.
32. Please describe a typical fourth meal or snack, including what time you eat it.
33. Please choose the types of fats you eat most often (check all that apply):
34. How's your poop?!
35. How would you describe your energy level?
36. Please describe your stress level.
37. How many times per day to you laugh?
38. How often do you have fun?
39. Do you have any problems sleeping?
40. Once you're asleep, do you have problems staying asleep?
41. When are you asleep? (Ex. 10pm to 7am)
42. Please select all of the items below that describe your support system. (All questions are optional.)
43. Have you ever been bitten by a tick?
44. Please check off any of the following that you may have experienced in the last 3 months or so.
45. Is there anything else you want me to know?
PLEASE READ The above information is complete and correct to the best of my knowledge. While I'm consulting with Anne, I understand that it's my responsibility to inform her if my health condition changes. I also understand that services at BuzzNutrition do not take the place of a physician’s care and that Anne Buzzelli does not diagnose ailments. Rather, she brings attention to patterns that may indicate an imbalance in health (via questions and lab testing) and then suggests foods, nutrients, herbs and lifestyle changes that may help your body regain balance. BuzzNutrition’s HIPAA Privacy Policy is available at www.BuzzNutrition.com/services .
