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Energe Clinic

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About Us
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Clinic
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Blogs
Contact Us

Book a Discovery Call

Home
About Us
Services
Clinic
Functional Testing
Wellness Product Store
Blogs
Contact Us
Book A Discovery Call

Home
About Us
Services
Clinic
Functional Testing
Wellness Product Store
Blogs
Contact Us
Book A Discovery Call

Book A Call

Please fill as much as you can where you feel appropriate. The one with stars are important. The rest is optional. Note that these data become important to address your situation.

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energeclinic@gmail.com

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Date Of Birth *

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Your Email *

Your Address *

Occupation *

Living Situation *

Children (ages) *

Height / Weight (if known)

Blood Pressure (if known)

Reason for completing this questionnaire today: *

Main symptoms / health concerns: *

Duration / how long have you had these concerns? *

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Please tick this box to confirm that you have read and agree to our Data Protection policy. We collect your personal information so we can contact you about the work we do and provide our services. We will never share your information with anyone else. Your contact details will be stored securely and will NOT be disclosed to third parties.

Please tick any that apply:Please tick any that apply:Chest discomfortShortness of breathNeurological changes (speech, vision, balance)Fainting / blackoutsBlood in stool / urine / vomitSevere abdominal painUnexplained weight lossNight sweats / persistent feverSudden behaviour or personality changes

Details:

(Include major illnesses, injuries, trauma, infections, surgeries, major stressors, life changes)

Childhood vaccines

Flu vaccines

Travel vaccines

COVID vaccinations

Reactions (if any)

Parents

Grandparents

Siblings/Children

Family conditions (tick):Family conditions (tick):Heart diseaseStrokeDiabetesThyroid conditionsAutoimmune conditionsCancerAllergies / AsthmaDementia / Alzheimer’s / Parkinson’sMental health conditions

1 — Nervous System & Emotional Regulation1 — Nervous System & Emotional RegulationOverthinkingAnxiety / panicFeeling overwhelmedIrritability or angerBrain fog / poor concentrationFeeling numb / “shut down”Feeling “wired but tired”Low stress toleranceMuscle tension / jaw clenching

Nervous system patterns (tick):Nervous system patterns (tick):FightFlightFreezeFawn

Notes

2 — Digestive System2 — Digestive SystemBloatingGas / burpingReflux / heartburnConstipationLoose stoolsNauseaUndigested food in stoolSymptoms worsen with stress

Bloating TimingBloating TimingImmediately after eating20–40 minutes after1–2 hours afterEnd of dayAll day

Food TriggersFood TriggersCarbsFatsProteinGlutenDairySugarVegetablesBeansUnsure

Improves WithImproves WithEatingNot eatingWarm drinksAntacidsSupplementsPassing gas or stool

Bristol Stool ChartSelect the type you most often experience:Type 1 — Hard lumps (constipation)Type 2 — Sausage-shaped but lumpyType 3 — Sausage with cracksType 4 — Smooth, soft, snake-like (ideal)Type 5 — Soft blobsType 6 — MushyType 7 — Watery

Bowel Movement FrequencyBowel Movement Frequency1–2 dailyDailyEvery 2–3 daysEvery 3–4 daysLess often

Feeling of incomplete emptyingFeeling of incomplete emptyingYesNoSometimes

Additional notes about bowel habits

3 — Hormonal System3 — Hormonal SystemFatiguePMSMood swingsLibido changesWeight changesSleep issuesHot flashes / night sweats

Women:

FlowFlowLightMediumHeavy

Symptoms (tick):Symptoms (tick):PMSCrampsClotsBreast tenderness

Perimenopause / menopause symptoms:

Men:Men:Low libidoFatigueMood changesHair changesReduced strength

Notes

4 — Immune System4 — Immune SystemFrequent infectionsSlow recoveryAllergiesChronic inflammationAutoimmune tendencies

Notes

5 — Detoxification & Environmental Load5 — Detoxification & Environmental LoadHeadachesFatigueSkin issuesSensitivity to smells/chemicalsBrain fog

Exposures:Exposures:MoldChemical cleanersHair/nail salon exposuresSmokeHeavy metalsPesticidesFrequent antibiotics

Notes

6 — Musculoskeletal System6 — Musculoskeletal SystemNeck tensionShoulder tensionBack painHeadachesMuscle stiffnessPain worsens with stress

Notes:

7 — Respiratory & CardiovascularRespiratory:Shallow breathingChest tightnessWheezingFrequent sighing

Cardiovascular:Cardiovascular:PalpitationsDizzinessCold extremitiesBreathlessness

Notes:

Past Experiences (tick any):Past Experiences (tick any):Childhood stress / instabilityEmotional neglectPhysical / emotional abuseBullyingBereavement / lossDomestic violenceMedical traumaAccidents / injuriesBirth traumaChronic stress / burnoutPrefer not to say

Current Impact:Current Impact:Mood changesSleep disturbanceDigestive changesPain or tensionOverwhelmHypervigilanceEmotional shutdown

Notes:

Column A — Sleep Routine

Bedtime

Wake time

Hours slept:

Sleep quality:Sleep quality:ExcellentGoodFairPoor

Night waking?Night waking?YesNo

Number of wakings:Number of wakings:1233+

What wakes you?What wakes you?UrinationAnxietyPainDreamsHeatNoiseUnsure

Column B — Night Waking Times & Recovery

Night waking timesNight waking times11pm–1am1–3am3–5amAfter 5amVaries

Fall back asleep:Fall back asleep:<10 min10–30 min30–60 min1+ hour

Morning energy:Morning energy:RefreshedOKTiredExhausted

Notes

SECTION 7 — NUTRITION & DIETARY PATTERNS

Diet style:

Foods avoided:

Food reactions:

Eating habits (tick):Eating habits (tick):Skip mealsEat on the runGrazeEmotional eating

Water intakeWater intake<1L1–2L2–3L3L+

CaffeineCaffeine012–34+

AlcoholAlcoholNoneOccasionalWeeklyDaily

Prescribed medications:

Non-prescribed / herbal products:

Supplements (include brands & doses):

Recently discontinued:

SECTION 9 — EXERCISE & LIFESTYLE

Movement frequency:Movement frequency:None1–2×/week3–4×/week5+

Types of activity

Stress management tools

Motivation for change (0–10):

SECTION 10 — READINESS FOR CHANGE

How ready are you to make dietary changes?How ready are you to make dietary changes?012345

How ready are you to take supplements (if appropriate)?How ready are you to take supplements (if appropriate)?012345

How ready are you to change lifestyle habits (sleep, hydration, stress)?How ready are you to change lifestyle habits (sleep, hydration, stress)?012345

How ready are you to adjust exercise/movement?How ready are you to adjust exercise/movement?012345

Obstacles / challenges to making changes

SECTION 11 — FINAL NOTES

Is there anything else you would like me to know before your appointment?

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energeclinic@gmail.com

Hours

Monday - Friday: 8-7PM
Saturday: Closed
Sunday: Closed

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