BREAKTHROUGH PROGRAMME

a glance at Your Health & life history

Time to dig a little deeper...

a snapshot of your health & life history...

Please take as much time as you need to complete this at a time that suits you.

In one sentence, why are you here?*
What are the 1 to 3 symptoms that affect you most right now?*
What have you already tried, and what happened?*
Please tick any that apply to you*
If you ticked any of the above, please provide brief details
What other diagnosed health conditions do you have, if any?*
What significant illnesses, accidents, operations or injuries have you had, if any?*
What medication are you currently taking, if any, and what's it for?*
What supplements are you currently taking, if any?*
How would you rate your sleep duration and quality?*
How would you rate your movement or exercise most days?*
What does your typical food intake look like in a day? (think about all your meals and snacks)*
How much plain water (tap/filtered/still bottled) do you typically drink in a day?*
Do you smoke or vape?*
How would you describe your work-life balance?*
What's most challenging about a typical day for you?*
Typically how many hours a day do you spend on devices (phone/laptop/computer/games console/tv)*
How would you describe your childhood?*
As an adult, have you experienced any particularly stressful periods or events? (for example, bereavement, relationship breakdown, work stress, illness, caring responsibilities)*
Imagine we're twelve months from now and everything has gone as well as it possibly could. What's changed? How are you feeling? What are you doing that you can't do now?*
What else, if anything, would you like Carolyn to know before your onboarding call?