Next Steps

Woohoo! Your appointment is officially booked!

Thank you for taking the time to complete this questionnaire. Your honest answers will provide us with a deeper understanding of your current health status, daily habits, and health goals, allowing us to better support you on your wellness journey. Get ready for some exciting insights. We’ll be sending you little email and text nudges, so peek at those – they’re packed with tips to make your session amazing. Please make sure you add care@scopeofhealth.com to your safe list. If you don’t see an email from that address, please look in the Spam or Promotions box.

To kick things off, let’s get to know your awesome self a bit better…

Your Health Snapshot Questionnaire

This is for your appointment for the LIVE and Dry Blood Cell Analysis. We’re excited to explore your health with you! It’s important to remember that our analysis is for preventative wellness, offering insights, not a medical diagnosis.

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Section 1: Lifestyle and Demographics

Email*

Your Full Name*

How old are you? (Your current age)*

What is your mailing address?*

What is your phone number?*

What is your current occupation?*

Please describe your typical workday/week in terms of activity level (e.g., mostly sitting, light movement, physically active):*

How would you describe your overall stress level on a scale of 1-10 (1 being no stress, 10 being extreme stress)?*

What strategies do you currently use to manage stress?*

How many hours of sleep do you typically get per night?*

Do you feel well-rested when you wake up?*

Yes

It varies

Do you exercise regularly? If so, what type and how often per week?*

How many alcoholic beverages do you consume per week (on average)?*

Do you consume caffeine? If so, what type and how much per day?*

Do you smoke or use any tobacco products - including vape products?*

Yes

Section 2: Dietary Habits & Hydration

Please describe your typical daily diet (e.g., omnivore, vegetarian, vegan, keto, etc.):*

How many meals do you typically eat per day?*

Do you eat breakfast every day?*

Yes

How many times per week do you typically eat out at restaurants or get takeout?*

What are your go-to "convenience" foods or snacks?*

How many glasses (8 oz) of plain water do you drink per day?*

What other beverages do you typically consume daily (e.g., soda, juice, coffee, tea)?*

Do you experience sugar cravings? If so, how often?*

Do you experience cravings for salty or savory foods? If so, how often?*

Are there any foods you believe you are sensitive or allergic to?*

Section 3: Digestion & Elimination

How many bowel movements do you typically have per day?*

Please describe the consistency of your bowel movements (e.g., firm, soft, loose, varies):*

Do you experience bloating or gas regularly?*

Yes

Sometimes

Do you experience heartburn or indigestion?*

Yes

Sometimes

How often do you experience constipation or diarrhea?*

Section 4: Current Health & Wellness Management

What current supplements are you taking? Please list them or take pictures and upload them (Or text the images to 949-293-6821 with your First Name and Last Initial)*

Picture(s) of Supplements

Max. file size: 256 MB.

What current medications are you taking and for what condition? Please list them or take pictures (Or text the images to 949-293-6821)*

Picture(s) of Medications

Accepted file types: jpg, jpeg, png, gif.

Do you have a primary care physician?*

Yes

If YES, what is their name and phone number?

Do you currently see a Chiropractor?*

Yes

If you are currently seeing a Chiropractor, what is their name and phone number?

Do you currently see a Naturopathic Doctor?*

Yes

If you are currently seeing a Naturopathic Doctor, what is their name and phone number?

Do you currently see an Acupuncturist?*

Yes

If you are currently seeing an Accupuncturist, what is their name and phone number?

Are you currently working with any other alternative health practitioners? If so, please list their modality, name, and phone number:*

What are your main health concerns or symptoms that prompted you to seek health guidance?*

Have you been diagnosed with any chronic health conditions? If so, please list them:*

Are you currently experiencing any pain? If so, where, and how would you rate it on a scale of 1-10?*

How would you rate your current energy levels on a scale of 1-10 (1 being very low, 10 being very high)?

Do you frequently feel fatigued or sluggish?*

Yes

Have you had any recent lab work or medical tests done? If so, please indicate, and we can discuss potentially reviewing them.*

Yes

Section 5: Health Goals & Aspirations

What are your top 3-5 health goals for the next 12 months?*

If we could wave a magic wand and help you achieve anything with your health in the next 12 months, what would that be?*

What would be some healthy milestones you would like to see from your 12-month health journey? (E.g., Improve Energy, Get off at least one medication, Reduce Pain, Better Sleep, Improved Digestion, Weight Management, Enhanced Mood, Increased Mobility, etc.)*

On average, how much do you estimate you spend monthly on groceries for healthy eating at home?*

On average, how much do you estimate you spend monthly on eating out/takeout?*

On average, how much do you estimate you spend monthly on supplements?*

On average, how much do you estimate you spend monthly on prescription medications (out-of-pocket costs)?*

Is there anything else you would like for me to know before your appointment?*

FOR WOMEN ONLY - Are you currently experiencing any hormonal changes or symptoms? (e.g. Menopause, Pregnancy, Menstrual Irregularities) Please describe*

Thank you again for completing this questionnaire. We look forward to reviewing your responses and discussing how we can best support your health goals.