Initial Consultation

Primary Health Goals: - Improve energy levels - Reduce chronic fatigue - Enhance sleep quality - Manage stress effectively Health History Pre-diagnosed illnesses and diseases: Medical Diagnosis: 1: Hypothyroidism, controlled, 2018 2: Anxiety, managed, 2020 3: Vitamin D deficiency, resolved, 2022 4: , , 5: , , 6: , , Current Supplements: - Vitamin D3 5000 IU daily - Magnesium Glycinate 200mg nightly Prescription Medications: - Levothyroxine 75mcg daily - Sertraline 50mg daily Allergies: - Penicillin Medical History Notes: - History of childhood asthma - Family history of diabetes - Previous surgery for appendicitis Lifestyle & Diet DIET - Are there any foods you avoid? - Gluten, dairy, and processed foods - Have you ever used a weight-loss diet? - Yes, the Paleo diet for 6 months - Do you use intermittent fasting? - Yes, 16/8 intermittent fasting - What are your favorite foods? - Salmon, avocado, and berries - Do you experience any symptoms after meals? - Occasional bloating after consuming dairy Diet Routine: - Follows a gluten-free diet - Drinks a smoothie for breakfast - Prepares meals at home - Avoids processed foods Breakfast - Smoothie with protein powder, spinach, and berries Lunch - Salad with grilled salmon and avocado Dinner - Chicken stir-fry with vegetables and brown rice Snacks/Sweets - Apple slices with almond butter Beverages - How much water do you drink daily? - 2 liters Do you consume caffeinated beverages? - Yes, one cup of coffee in the morning Do you consume alcohol? - Occasionally, a glass of wine List any other drinks you consume: - Herbal tea STRESS/SLEEP - Stress Patterns What level of stress are you currently experiencing? - Moderate List your main stressors: - Work deadlines, financial concerns, relationship issues What helps you decompress? - Yoga, meditation, and spending time in nature Sleep Patterns - How many hours do you sleep at night? - 7 hours - Do you have good quality sleep? - Sometimes - Do you wake feeling rested? - Sometimes EXERCISE - How often do you exercise? - 3 times per week - What types of exercise do you do? - Yoga, walking, and weight training Additional Notes - How many hours per week do you use a computer? - 30 hours - How many hours per day do you use a smart phone? - 2 hours - Do you or have you used recreational drugs? - No - Do you use nicotine products? - No - If yes, what kind? - ACTION PLAN: - Nutrition: - Increase intake of omega-3 fatty acids through diet or supplementation. - Reduce consumption of processed foods and refined sugars. - Consider a food sensitivity test. - Exercise: - Continue with current exercise routine. - Incorporate more cardio, such as running or cycling. - Aim for at least 150 minutes of moderate-intensity exercise per week. - Stress/Sleep: - Practice daily meditation for 15 minutes. - Establish a consistent sleep schedule. - Consider a sleep hygiene routine. - Supplements: - Continue Vitamin D3 and Magnesium Glycinate. - Consider adding a probiotic. - Miscellaneous: - Schedule a follow-up appointment to review progress. - Consider a consultation with a therapist. Follow-up: - 4 weeks