NATUROPATHY

Empowering Health Naturally

Lifestyle:

Name

Diet: Overview of dietary habits including regular meals, dietary restrictions or preferences (e.g., vegetarian, gluten-free), and typical daily fluid intake.

Weight Management: Goals related to weight (loss, gain, maintenance) and any past efforts or challenges.

Exercise Routine: Description of regular physical activities, types of exercises performed, frequency, duration of sessions, and any recent changes in activity level.

Sleep Patterns: Information on sleep habits, average hours of sleep per night, sleep quality, any difficulties falling asleep or staying asleep, and daytime fatigue levels.

Stress Levels: Self-assessment of stress levels on a scale, factors contributing to stress (e.g., work, family, health concerns), and methods currently used to manage stress.

Menstrual History (for Women): Regularity of menstrual cycles Duration and flow of periods Symptoms associated with menstruation (e.g., pain, mood changes) History of menstrual disorders (e.g., PCOS, endometriosis)

Fertility and Conception (for Women): Plans for pregnancy or current attempts to conceive. History of pregnancies (if applicable). Use of fertility awareness methods or assisted reproductive technologies.

Sexual Health (for Both Men and Women): Concerns or symptoms related to sexual function or libido.

Hormonal Balance (for Both Men and Women): Symptoms of hormonal imbalance (e.g., fatigue, mood swings, weight changes). History of hormonal disorders (e.g., thyroid disorders, adrenal issues) Use of hormone replacement therapy or natural hormone support.

Other Pertinent Info: Please provide any additional health information that you believe is important for us to know.

By clicking "Submit," I consent to receive naturopathic consultation and treatment from Visacova Santé. I understand the nature of naturopathic services, including potential benefits and risks. I agree to participate voluntarily and understand that my health information will be kept confidential. Each page of this form must be submitted independently to ensure all information is received and processed accurately.

Initial Consultation Price: $55 plus tax

Insurance receipts provided with every consultation.

Explore our massotherapy treatments at Visacova Santé.

Massotherapy

NATUROPATHY

Empowering Health Naturally

Lifestyle:

Massage