Your True North Questionnaire

Please fill out the following questionnaire so I can get to

know you, and have a better understanding of who you

are as an individual so I can best serve you.

Jen Johnston

Full Name *

Address *

Phone *

Email *

Date of birth *

Height *

Weight *

Biomedical Data:

What are your top three health complaints/concerns? *

What are your health goals? (If more than one please list in order of priority to you) *

Please list and describe the onset and occurrence of any health concerns, skin issues, diagnoses, symptoms, etc. *

How have you dealt with these concerns in the past? *

What other health practitioners are you currently seeing? *

Please describe any family history of health concerns *

Have you had an surgeries? If so, please list what type and when. *

List current medications - dose and how long you have been taking them (including any form on birth control) *

List any supplements you are currently taking (please specify starting date, time of day you take them, brand name and dosage). *

Any known food allergies, sensitivities or foods you prefer to avoid? *

Personal Lifestyle:

Occupation/ Full-time, part-time? How many hours per week do you work? *

Do you travel often? *

Describe your current exercise/recreation (duration and # of times per week): *

What does a typical timeline of your day look like for you? Wake, eat, work, workout, sleep, etc. Please write out. *

What are your hobbies? *

In your opinion, what is the biggest roadblock preventing you from reaching your goals? *

What would be possible in your life if this were to change? *

What new habits would you like to adopt? *

Biofeedback:

Current # of hours of sleep per night on average? Do you wake up feeling rested? *

Do you have trouble falling asleep at night? *

Do you wake up throughout the night? If yes, how many times are you able to go back to sleep easily? *

Do you have any digestive symptoms such as frequent bloating, gas, belching, heartburn, indigestion, acid reflex, etc.? If yes, how long has this been going on? *

Have you ever had food poisoning or travelers diarrhea? If so, please list when and if you noticed any changes in digestion or health after this. *

How are you bowel movements? Frequency? Formed or loose? Contain undigested food? Etc. *

Describe your energy levels throughout the day: *

Describe your current stress on average and sources of stress: *

Describe your current soreness/recovery from workouts on average: *

Describe your current hunger throughout the day on average: *

For Females:

How old were you when you stared menstruating? How are/were your cycles? How long are your cycles? How many days do you bleed? What is your flow like? Do/did you have PMS? Painful periods? Etc.

Are you currently breastfeeding? If so for how long?

Nutrition:

Please share some detail around your younger years. As a child, were you sick a lot? What was your nutrition like during your upbringing and throughout your life? *

How long does it take for you to consume a meal? *

How many meals/snacks a day do you eat on average? *

How many of your meals per day are consumed while sitting and free from from tv, phone, computer, driving, or standing, etc.? *

How much caffeine do you consume in a day on average & when? *

How many alcoholic beverages do you consume per week on average? *

How many oz of water do you consume per day on average? *

How many meals a week do you eat out on average? *

What kind of cooking oils do you use? *

In your opinion, what are the three least healthy foods you eat each week and why? *

In your opinion, what are the three healthiest foods you eat each week and why? *

What is your current system (if any) for grocery shopping and meal planning/prepping? Are you happy with this current system and do you it works well for you? *

Do you do a majority of your grocery shopping? Where do you shop? *

How would you describe your relationship with food as it is right now? *

On a scale of 1-10 (10 being very committed). How committed are you to making changes to reach your goals? Including lifestyle, dietary, and/or supplement *

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Any other relevant information you feel I should know or would like to share?