Name

Email Address

Date of birth

Age

Contact Number

How much do you weight?

What is your ideal weight?

How tall are you?

Occupation

How were you referred to me?

Please list prescribed medications you are taking and for how long.

Do you have a DUTCH lab? Do you have a DUTCH lab? Yes No I am waiting for my results

Please list any hormones you are taking, how long, total daily dose, patch, topical, oral, pellets, injections, pills and don't forget melatonin and cortisone products. Also describe your experience on hormones.

Please list your nutritional supplements. Briefly tell me which supplements you believe make a positive difference in your health.

What are your chief health complaints?

Do you get at least 5-7 hours of uninterrupted sleep per night. If not please elaborate.

Please describe your digestion. Please describe your digestion. Bloating Burping Heartburn/GERD Sleepy following meals Gassy Other

Please describe your libido Please describe your libido Low libido No drive but fine once I get started Normal High libido Repulsed by sex Libido is ok but vaginal dryness or pain or atrophy

How are your bowel movements? How are your bowel movements? Once per day Normal Constipated often Less than once per day Too frequent Too runny Too smelly Hard to pass Hemorrhoids Other

How is urination? How is urination? Normal every 3 hours Too frequent Wake up during the night to pee Painful Weak stream Blood or dark in color Have had/have kidney stones Frequent UTI's or Bladder infections or IC Leaking or incontinence Other

Please describe in detail your cycles or your menopausal experience. *

Do you exercise regularly? If so or no, explain.

How is your dental health? This question matters because even low grade dental infection can have an impact on your hormones, immunity and gut health. Please elaborate on your restorations, dead teeth, crowns etc..

Check all that apply: "I drink or eat..." Check all that apply: "I drink or eat..." Caffeine Alcohol Artificial Sweeteners Fast food, take out Restaurants often Restaurants sometimes Restaurants special occasions/rarely Grains Gluten PUFA/ Seed oils like canola, vegetable, sesame Fried foods Highly processed packaged foods Non-organic produce I smoke cigarettes

Please describe your average breakfast

Please describe your average lunch

Please describe your average dinner

Please describe your snacks, time and frequency, include cravings

Are you seeing any medical professionals or other practitioners at the present time?

What do you hope to gain from our consult?

Is there anything else you'd like to share with me that is not covered in this questionnaire? Major surgeries or accidents that could impact your medical history?

"I am aware that Catalina (Kitty) Martone is NOT a medical doctor, she is a health educator and does not intend to diagnose, treat or cure any ailment, illness or disease I may be suffering from. " "I am aware that Catalina (Kitty) Martone is NOT a medical doctor, she is a health educator and does not intend to diagnose, treat or cure any ailment, illness or disease I may be suffering from. " Agree