Health Assessment
Please answer all questions to the best of your ability so we can assess your health needs. 
Email *
Name
Age
List any current physical health concerns (Diagnosed conditions or physical symptoms)
List any current mental health concerns 
List any current emotional health concerns
Please list if you have had any of the following labs done-
List any current medications/supplements/vitamins you are taking
List what you have tried to remedy your current physical/emotional/mental concerns
List what goals you have for your physical health
List what goals you have for your mental/emotional health
List any allergies (food, environmental or medication)
Please give examples of foods you frequently eat
Have you gained weight in any of the following areas?
Are you exhausted when you first wake up despite how many hours of sleep you've gotten? 
Do you get "wired" right before you are supposed to go to bed and then cannot fall asleep? 
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Are the bottom of your feet tender in the mornings?
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Describe the stressors in your life
How often do you exercise?
How often do you meditate?
How many hours a night do you sleep?
Do you wake up during the night? If so, how often during the night?
How many hours a day are you on technology or exposed to EMF frequencies such as smart phones, computers or laptops?
Do you have a set daily routine?
How often do you do activities you enjoy?
Do you have a support system? If so, do you engage with them on a regular basis?
What is your greatest fear?
Describe yourself in three words?
What food cravings do you experience?
What times during the day do you experience hunger? 
What time do you naturally wake up? 
Time
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Are you hungry frequently?
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How much water do you drink daily?
Are your bowel movements regular?  
What is the content of your stool?
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How often do you have bowel movements?
Do you urinate frequently?
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Do you have trouble falling asleep?
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Are you frequently stressed?
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What do you do to relax?
Are your menstrual cycles regular?
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How painful is your menstrual cycle? 
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How often do you get sun exposure?
What is your typical response to stressful situations? 
Do you eat sugar? 
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Are you able to digest food well? 
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Disclaimer statement.
I understand that services by Winslow E. Dixon are not a replacement for medical treatment or advice and should not be used to provide medical care.  Counsel by Winslow E. Dixon is only to be used in conjunction with an overseeing medical professional. Program success is dependent on a variety of factors such as personal effort, genetics, and support. I understand that Winslow E. Dixon is a clinical herbalist, holistic health practitioner and hormone health specialist and not a licensed medical doctor. 

All hormone tests are performed by our affiliate, ZRT laboratory. Payments for hormone tests must be made directly to ZRT. We receive no compensation for the use of ZRT's lab testing protocols.   
By typing my name in the space below, I acknowledge the above statement and understand Winslow E. Dixon's counsel should not be used as medical advice and should only be used as educational information. 
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