Part One
Your Health Timeline
Question 1
When did you last feel well?
Not "okay." Not managing. Actually well — energy, sleep, clarity, ease in your body. Write down the year or the period.
Question 2
What changed around that time?
New home, new job, new relationship, pregnancy, loss, surgery, a medication started, a move to a new city, a period of extreme stress. The body tracks these. What happened in the 6–12 months before things shifted?
Question 3
What has been constant in your environment?
Where do you sleep? What do you drink? What are you exposed to daily that you've never questioned? These constants are often the most overlooked drivers of chronic symptoms.
Question 4
What have you already tried?
What didn't work tells us something. If a diet worked briefly then stopped, if a supplement helped for six weeks then stopped, if energy improves on vacation but crashes at home — the body is communicating. Document what you've tried and how each went.
What I tried
How long
What happened
Question 5
Structural history — impacts your body has absorbed
The body remembers physical impact long after the mind moves on. A coccyx injury from a hard fall decades ago can restrict CSF flow indefinitely. Ankle sprains that were never properly treated alter gait mechanics through the hips and spine. These are terrain inputs conventional medicine never captures.
Question 6
Women's health history — what has been part of your story
These are terrain markers, not judgments. Each one tells the practitioner something specific about the interference pattern. Mark everything that applies.
Part Two
Current Symptom Picture
Energy & Sleep
Brain & Nervous System
Hormones & Metabolism
Gut & Digestion
Pain & Inflammation
Symptoms not listed, or patterns you've noticed:
Part Three
Your Medications
Current Prescriptions
| Drug name | Dose | Reason prescribed | Started | Prescribing doctor |
|---|---|---|---|---|
Supplements
| Supplement name | Dose | Reason taking | Started | Recommended by |
|---|---|---|---|---|
Questions I have about my current medications:
Part Four
Urine Tracking
Color Reference
Crystal clear / colorless = overhydrated — you are flushing minerals · Pale yellow = optimal · Yellow = adequate · Dark yellow = dehydration · Amber/orange = dehydrated or liver stress · Brown/dark = urgent — seek evaluation · Cloudy = possible infection or high mineral load · Pink/red = blood — seek evaluation
Overhydration note: drinking large amounts of plain water — especially reverse osmosis or distilled — depletes sodium, potassium, and magnesium through increased urinary excretion. Crystal-clear urine all day is a warning sign, not a goal.
My urine color today (select one):
Frequency:
Symptoms & Patterns
Patterns or changes you've noticed:
Part Five
Bowel Health
Bristol Stool Chart Reference
Type 1 = Separate hard lumps (severe constipation) · Type 2 = Lumpy sausage (mild constipation) · Type 3 = Sausage with cracks (normal) · Type 4 = Smooth soft sausage (optimal) · Type 5 = Soft blobs with clear edges · Type 6 = Fluffy pieces, mushy edges · Type 7 = Watery, no solid pieces (diarrhea)
My typical stool type (select one):
Frequency:
Symptoms & Observations
Changes in the last 6 months:
Part Six
Sleep
Sleep Patterns
Sleep Quality
Duration:
What helps vs. what disrupts your sleep:
Part Seven
Light
Light Audit
Outdoor time (most days):
Changes you could make to your light environment:
Part Eight
Water
Primary Water Source (select one):
Water Container
Intake & Electrolytes
Daily intake estimate:
What you know or suspect about your water quality:
Part Nine
EMF Audit
Sleep Environment
Body Exposure
Home Infrastructure
Exposures you've accepted as normal that you've never questioned:
Part Ten
Toxic Load
Food
Kitchen
Home & Personal
What toxic loads have you already reduced, and what felt different?
Part Eleven
Emotions & Stress
Current Emotional Load
What emotional loads are you currently carrying?
What has helped you regulate — even temporarily?
Part Twelve
Your First Step
Which area feels most urgent for you right now?
A 30-day commitment
Most meaningful changes take 30 days to show a signal. Write what you're committing to and how you'll know if it's working.
30-Day Check-In
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