Name
*
First Name
Last Name
Email
*
Age
Gender
Female
Male
Non-binary
Prefer not to say
Dominant hand:
Right
Left
Ambidextrous
Occupation
What are your current main health concerns?
What are you struggling with most?
What were you like as a child — physically and emotionally?
Include childhood illnesses, fears, sleep patterns, energy, personality, and how you coped with stress.
Do you generally run hot or cold?
Hot
Cold
Mixed / variable
Room temperature preference:
Prefer warmth
Prefer cool
No strong preference
Open air vs closed rooms:
Crave fresh/open air
Prefer enclosed/cozy spaces
Depends
Cravings (check all that apply):
Aversions or food sensitivities
Appetite
Low
Normal
Strong
Fluctuates
Thirst
Low
Normal
Excessive
When do you usually go to bed? When do you usually wake up?
Sleep quality
Deep sleeper
Restless, trouble falling asleep
Frequent waking
Insomnia, trouble sleeping
Usual sleep position
Back
Side
Stomach
Varies
Dream themes (if notable)
When in the day do you feel your most energetic?
How do you feel after exercise?
Energized
Calm/grounded
Wiped out/ Exhausted
Depends on intensity
Describe your current body frame
Thin/Delicate
Average
Muscular/Athletic
Soft/Heavier
Hair (texture, color, graying, hair loss)
Perspiration (easily? areas? odor?)
Usual mood (on average)
Cheerful
Anxious
Irritable
Low/Depressed
Calm
Changeable
How do you respond to stress/criticism?
Company vs solitude
Prefer company
Prefer solitude
Depends
Fastidious vs messy
Fastidious/order-loving
Easygoing with mess
Mixed
Crying tendency
Rare
Occasional
Frequent/Easily moved
Anything notable about relationships, family, or authority dynamics?
Do you experience headaches, dizziness, or mental fog?
Any issues with vision, dryness, watering, or light sensitivity?
Do your eyes get tired easily or have floaters?
Any ringing, hearing loss, ear infections, or sensitivity to noise?
Do you often have congestion, allergies, sinus pressure, or loss of smell?
Do you get sore throats, mouth ulcers, bad breath, or hoarseness?
Any dental issues, bleeding gums, or cracked lips?
Any cough, asthma, shortness of breath, chest tightness, or frequent colds?
Any palpitations, skipped beats, chest pain, or poor circulation (cold hands/feet)?
Do you ever feel dizzy when standing quickly?
Do you experience bloating, gas, constipation, diarrhea, or heartburn?
Question (men): Any urinary frequency, nighttime urination, or prostate concerns?
Question (women): Are your periods regular, painful, heavy, or irregular?
Any PMS, menopausal symptoms, or vaginal dryness/discharge?
Changes in libido?
Do you experience stiffness, joint pain, back or neck pain, muscle weakness, or cramps?
Any pattern (morning, damp weather, after rest, after activity)?
Any rashes, dryness, itching, acne, eczema, or slow wound healing?
Do you tend to get warts, moles, or hives?
Do you tend to gain or lose weight easily?
Any thyroid concerns, fatigue, hair loss, or intolerance to heat or cold?
How rested do you feel on waking?
Do you ever wake at the same time each night or feel sleepy after meals?
Do you ever feel any sensations in your body that are unusual or difficult to describe?
Examples: “as if insects were crawling,” “as if a band around the head,” “as if heart stops then starts again,” “as if floating,” “as if something alive inside,” etc.
Do you have any reactions to your surroundings that seem peculiar or out of the ordinary?
For instance: can’t tolerate certain sounds, lights, or smells; sneeze in sunlight; itch when undressing; feel anxious in crowds or small spaces; get dizzy from certain colors or lights.
Do you notice any strange recurring patterns in your symptoms or mood?
e.g., every other day headaches, same time every year, mood dips before a storm, symptoms switch sides of body, better one day, worse the next.
Do you ever react emotionally in ways that surprise you or others?
Examples: laughing or joking when sad, crying when angry, feeling worse when comforted, feeling better when alone, sudden intense irritation over small things.
Any very specific or bizarre features of your sleep or dreams that stand out as unusual?
e.g., always wake same time with panic, dreams of falling, teeth, or water, feel worse after naps, wake unrefreshed despite long sleep.
Do you have any unusual preferences or sensitivities — to touch, music, smells, textures, or sensations?
e.g., love thunderstorms, hate being touched, feel peaceful from certain sounds or smells, crave pressure or massage, hate wool or tags.
Was there a time or event after which your health noticeably changed?
e.g., after a pregnancy, infection, emotional trauma, or life change.
What activities, people, or values make you feel most alive or fulfilled?
Is there anything else — physical, emotional, or behavioral — that feels uniquely “you,” even if it doesn’t seem relevant to your health?
Small quirks, habits, rituals, or patterns others might notice — anything that stands out.
Consent
*
I consent to submit this information for care with Dr. Mark Iwanicki.
