Functional Chronic Wellness

1) Female-Specific Risk & History

Have you ever been diagnosed with an autoimmune disease?

Yes No

Did your symptoms begin after puberty?

Yes No

Did your symptoms begin post-pregnancy / postpartum?

Yes No

Did your symptoms begin after miscarriage or abortion?

Yes No

Did your symptoms begin during perimenopause / menopause?

Yes No

Do autoimmune or thyroid conditions run in your family?

Yes No

Have you experienced symptom worsening around your menstrual cycle?

Yes No

2) Menstrual & Reproductive Health

Are your menstrual cycles irregular?

Yes No

Are your menstrual cycles painful?

Yes No

Do you experience severe PMS or PMDD?

Yes No

Do you experience heavy or prolonged bleeding?

Yes No

Do you experience missed periods?

Yes No

Have you been diagnosed with PCOS or Endometriosis?

Yes No

History of infertility or recurrent pregnancy loss?

Yes No

3) Hormonal & Metabolic Clues

Do you experience unexplained weight gain or weight-loss resistance?

Yes No

Cold intolerance or heat intolerance?

Yes No

Hair thinning or hair loss?

Yes No

Low libido?

Yes No

Mood changes related to your cycle?

Yes No

History of thyroid dysfunction or postpartum thyroiditis?

Yes No

4) Energy, Fatigue & Sleep

Do you feel chronically fatigued despite adequate rest?

Yes No

Do you wake up feeling unrefreshed?

Yes No

Do you experience energy crashes during the day?

Yes No

Difficulty falling asleep or staying asleep?

Yes No

5) Inflammation & Pain Patterns

Do you experience joint pain or stiffness?

Yes No

Morning stiffness lasting >30 minutes?

Yes No

Migratory pain (moves from joint to joint)?

Yes No

Do symptoms fluctuate in flares and remissions?

Yes No

6) Gut & Immune Health

Do you experience bloating, gas, or abdominal pain?

Yes No

Constipation or diarrhea?

Yes No

Food sensitivities?

Yes No

History of IBS, IBD, or celiac disease?

Yes No

Frequent antibiotic use?

Yes No

Do symptoms worsen after infections?

Yes No

7) Skin, Hair & External Clues

Dry skin?

Yes No

Rashes or photosensitivity?

Yes No

Eczema or psoriasis?

Yes No

Brittle nails or slow nail growth?

Yes No

8) Neurological & Mood Symptoms

Brain fog or memory issues?

Yes No

Anxiety or depression without clear cause?

Yes No

Tingling, numbness, or burning sensations?

Yes No

Headaches or migraines?

Yes No

9) Stress, Trauma & Lifestyle Triggers

Chronic emotional stress?

Yes No

Major life trauma?

Yes No

Sleep duration <7 hours regularly?

Yes No

High stress levels?

Yes No

10) Autoimmune Red Flags

Unexplained fevers?

Yes No

Rapid unexplained weight loss?

Yes No

Persistent swelling?

Yes No

Vision changes?

Yes No

Blood in stool or urine?

Yes No

Health Assessment Form

Personal Information

1) Female-Specific Risk & History

2) Menstrual & Reproductive Health

3) Hormonal & Metabolic Clues

4) Energy, Fatigue & Sleep

5) Inflammation & Pain Patterns

6) Gut & Immune Health

7) Skin, Hair & External Clues

8) Neurological & Mood Symptoms

9) Stress, Trauma & Lifestyle Triggers

10) Autoimmune Red Flags

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