Which medical conditions have you been diagnosed with and in which year?
Which medications do you take and in what doses?
Do you have allergies to medications, food, animals or the environment? What allergic reaction do you get?
Which surgeries have you had and in which year?
Have you been diagnosed with mental health conditions? Do you have mental health concerns?
Have you had pregnancies? Are you perimenopausal/menopausal? Any gynecologic medical/history or concerns?
Please name the specialists you have seen, when and why
Please describe medical conditions (e.g. cancer, heart attack, diabetes etc.) in your parents, grandparents, siblings, and children
We'd love to get to know you! Who do you live with? Are you married? What is your spouse's name and occupation? Do you have children and what are their names/ages?
Do you smoke cigarettes or vape? If so, how much? Have you quit and if so, when?
How much alcohol do you drink per week?
Do you use other substances e.g. cannabis, other recreational drugs? How often?
What is your diet like? Do you have any goals for your diet?
Do you taken any vitamins or supplements and in which doses?
What do you do for exercise? How many minutes per week of exercise?
Do you sleep well? Do you have concerns about your stress level?
What are your goals for your relationship with your doctor? Anything else we should know?