Pathways Assessment

Step 1 of 10

10%

My practitioner is:(Required)

Email(Required)

Name(Required)

First Last

Date of Birth(Required)

Day

Month

Year

1/9 Energy and Sleep

My sleep is usually disrupted, I have trouble falling asleep or staying asleep(Required)

Yes

Please explain how your sleep is disrupted more

I feel tired a lot(Required)

Yes

Please explain your fatigue and its patterns more

I experience night terrors, nightmares or sleep paralysis(Required)

Yes

Please explain the night terrors, nightmares or night paralysis more

I often remember my dreams(Required)

Yes

My dreams are dull(Required)

Yes

I have bad thoughts and anxiety at night(Required)

Yes

2/9 Pain, Neurological

I have a lot of aches and pains(Required)

Yes

Please explain your aches and pains more

I am sensitive to pain, have a low pain threshold(Required)

Yes

Please explain your pain threshold more

I experience numbness, tingling on parts of my body(Required)

Yes

Please explain your numbness or tingling more

Explain your relationship with alcohol(Required)

I never drink alcohol

I do drink

Drink to relax every day, get drunk at parties, drink to manage anxiety, etc.

Please explain your use of alcohol further

Explain your use of psychoactive medications/drugs(Required)

I never take psychoactive medications/drugs

I do take psychoactive medications/drugs

Not telling - to discuss later!

e.g. sedatives (sleep), anti-anxiety, mood stabilisers, stimulants, ecstasy/MDMA, methamphetamine, opioids (including methadone), disassociatives (ketamine), hallucinogens (magic mushrooms, LSD), cannabis (and derivatives), pain medication, etc.

Please explain your use of psychoactives further

I live with chronic pain(Required)

Yes

Please explain your pain more

I have joint pain(Required)

Yes

Please explain your joint pain more

I am jiggly, fidgety, can't sit still(Required)

Yes

Please explain your fidgeting more

I often feel I'm in a state of hypervigilance(Required)

Yes

Please explain your hypervigilance more

I feel anxious a lot(Required)

Yes

Please explain your anxiety more

Exercise makes me feel better(Required)

Yes

No, it makes me feel worse

Please explain your exercise response more

I have poor coordination, am clumsy(Required)

Yes

Please explain your coordination more

I have poor balance(Required)

Yes

Please explain your balance more

3/9 Mental, Emotional, Cognitive

I often find I can't recall names or places, or struggle to find the right words(Required)

Yes

Please explain your recall more

I have been diagnosed/suspected of having one of the following:(Required)

None

Bipolar

Schizophrenia

OCD

Major depression or general depression

Anxiety disorder

Personality disorder

PTSD

ADD/ADHD

Autism spectrum disorder

Disordered eating

Other

Please explain your psychiatric diagnosis more

I feel emotionally numb(Required)

Yes

I feel overwhelmed(Required)

Yes

I feel angry(Required)

Yes

I get easily or frequently irritated or agitated(Required)

Yes

I find it difficult to control my emotions(Required)

Yes

I feel depressed(Required)

Yes

I experience low mood(Required)

Yes

I experience mood swings(Required)

Yes

I have thoughts of suicide(Required)

Often

Sometimes

In the past

Explain your thoughts of suicide more

I can't think properly(Required)

Yes

Explain being unable to think properly more

I forget what I'm talking about mid-conversation(Required)

Yes

Explain losing track of conversations more

I have brain fog(Required)

Yes

4/9 Detoxification

I experience headaches or migraines(Required)

Headaches

Migraines

I had general anaesthesia and things started going wrong(Required)

Yes

I am sensitive to caffiene(Required)

Yes

I get rashes(Required)

Yes

I have in the past or do react badly to B vitamin supplements(Required)

Yes

I am very sensitive to ingredients in supplements and herbs(Required)

Yes

I am very sensitive to my environment (cleaning products, smoke, perfume, chemicals, etc.)(Required)

Yes

I have sensitive skin(Required)

Yes

I am allergic to sulfa medications(Required)

Yes

I am salicylate intolerant (aspirin, etc.)(Required)

Yes

Not straightforward - to discuss

My alcohol tolerance is poor(Required)

Yes

5/9 Diet, Digestion

Certain foods upset my digestion(Required)

Yes

Please explain which foods upset your digestion

I am a vegetarian or vegan(Required)

Vegetarian

Vegan

Mostly plant-based, Flexitarian

I don't eat much meat for another reason

I get pimples on my body(Required)

Yes

I have food or other allergies(Required)

Yes

Please explain what you are allergic to

I have regular digestive problems(Required)

Bloating

Gas

Diarrhoea

Loose stools

Floaty stools

Pellety stools

Stool sticks to the toilet bowl

I have to wipe a lot after a bowel movement

Incomplete evacuation

Constipation

IBS

Crohn's

Ulcerative colitis

Digestive pains

Reflux, GERD/GORD

Sluggish digestion

Burping/belching

Nausea

Vomiting

Other uncomfortable digestive symptoms

Please explain your digestive issues more

I have had my gallbladder removed or have/have had gallstones(Required)

Gallbladder removed

Gallstones removed

Gallbladder issues

6/9 Immune

I have allergies(Required)

Yes, severe

Yes

I have or have in the past had frequent sinus, ear and other upper respiratory tract issues(Required)

Yes, severe

Yes

I get frequent coldsores or herpes outbreaks(Required)

Yes

I am prone to yeast infections (mouth, genitals, etc.)(Required)

Yes

I get frequent urinary tract symptoms, infections, bladder pressure, etc.(Required)

Yes

I have been diagnosed with autoimmune disease(Required)

Yes

Please explain your autoimmune diagnosis

I have been diagnosed with or have suspected Lyme disease(Required)

Yes

I have been diagnosed with or suspected of having mould toxicity(Required)

Yes

7/9 Reproductive, Gynaecological, Urinary

I get frequent genital infections, symptoms or imbalances(Required)

Yeast

DIV

Mystery

I get frequent urinary tract infections or have chronic UTI(Required)

Yes

I have had one or more miscarriage(Required)

Yes

My periods could be described as: (choose all that apply)(Required)

I do not get periods

I'm perimenopausal

I'm menopausal

I have irregular periods

1-3 days long

3-5 days long

5-7 days long

7+ days long

Heavy

Light

Painful

Clotty

Pain free

Put me out of action for one or more days

I get premenstrual symptoms (PMS)

I have PMDD

I am suspected or have been diagnosed with(Required)

None of these

Polycystic ovarian syndrome (PCOS)

Endometriosis

Fibroids

Polyps

Ehlers-Danlos Syndrome (EDS)

Mast-cell Activation Syndrome (MCAS, MCAD)

I have unexplained infertility(Required)

Yes

8/9 Metabolism

I have diabetes, prediabetes, insulin resistance or blood sugar issues myself or in my family(Required)

Yes

I often crave:(Required)

Sugar or carbohydrates

Protein (meat)

Salt

No cravings

Another craving

I crave:

I tried the ketogenic diet and:(Required)

I have not tried the ketogenic diet

My mood improved

My energy levels improved

I felt horrible

I felt fine, no major changes

I don't tolerate sulphurous foods like onions, garlic, eggs, cauliflower, broccoli, cabbage(Required)

Do tolerate

Don't tolerate

When I eat dairy, bad things happen(Required)

Yes

I have thyroid issues(Required)

Yes, hyperthyroidism

Yes, hypothyroidism

Thyroid autoimmune disease (Grave's, Hashimoto's)

I find it difficult to put on weight(Required)

Yes

I find it difficult to lose weight(Required)

Yes

9/9 Overall Health, Misc

I have had health problems my whole life(Required)

Yes

Others in my biological family have similar or many health problems(Required)

Yes

I have unusual or unexplained blood test results on routine tests(Required)

Yes

Which tests?

I have high cholesterol(Required)

Yes

My blood pressure is always high/low(Required)

High

Low

Blood pressure is normal

I experience dizziness(Required)

Yes

I get heart palpitations(Required)

Yes

I get rapid heartbeat(Required)

Yes

I tend towards water retention(Required)

Yes

I get a dry mouth(Required)

Yes

I often feel nauseous with or without vomiting(Required)

Yes

I grew up or live somewhere where a lot of people get sick with the same problems(Required)

Yes

I have high heavy metal loads (mercury, lead, etc.)(Required)

Yes

I don't know

I have been diagnosed with epilepsy or experience seizures(Required)

Yes

I get tinnitus(Required)

Yes

I always have low ferritin or iron even though I eat meat(Required)

Yes

Don't know

I bleed or bruise easily(Required)

Yes

I have blood vessel issues (varicose veins, spider veins, broken blood vessels, etc.)(Required)

Yes

Please add any additional information here