NEW CLIENT EVALUATION

This form is for new clients who have scheduled or are planning to schedule a comprehensive consultation. Please complete all sections as accurately as possible. The information you provide will be reviewed prior to your session to help us understand your health background, main concerns, and goals. This evaluation includes a detailed review of your health history and systems, followed by a phone consultation. Please upload any recent lab results or relevant medical reports to assist in the assessment.

If you have more than 30 files or large documents to share, please reach out through the Contact Form to request a secure upload link.

Client Evaluation

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary health concerns or goals

Current diagnoses (if any)

Height / Weight

Known allergies or sensitivities (food, environmental, chemical, medication)

Major illnesses or surgeries

Family history (heart disease, diabetes, cancer, autoimmune, etc.)

Current or chronic symptoms.

Current medications (name, dose, purpose)

Current supplements or herbs (name, dose, frequency)

Any adverse reactions to supplements or medications

Typical daily diet (brief description or sample day)

Water intake per day

Caffeine / alcohol use

Tobacco or recreational drug use

Exercise routine

Sleep pattern and quality

Occupation and daily stress level

Emotional well-being (1–10 scale or brief description)

Current living situation (house, apartment, etc.)

Year of home construction

Known mold, chemical, or EMF exposure

Type of water used (tap, filtered, well, bottled)

Pets in the home

Use of scented or chemical cleaning/laundry products

Use of pesticides, insecticides on the property

Menstrual cycle (regular, irregular, menopausal, postmenopausal). Leave blank if does not apply.

Birth control or hormone therapy. Leave blank if does not apply.

Pregnancy history. Leave blank if does not apply.

Labs and Test Results Upload. You may upload up to 30 files directly here. For larger submissions or additional documents, please contact us through the Contact section to receive a secure upload link.

I understand this service provides health coaching, not medical diagnosis or treatment. I consent to data collection for assessment purposes. By submitting this form, you agree to receive occasional updates and communications from Ecosystem Health. You can unsubscribe at any time using the link provided in our emails.

NEW CLIENT EVALUATION

Client Evaluation

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