Fitrah HealthStep 1 of 4 Before we speak Your intake form This helps me understand you before our call, so we can spend the time on what matters. It takes about 10 minutes. You'll only ever fill this in once. Full namePlease add your name. EmailPlease add a valid email. AgePlease add your age. Sex FemaleMale Please choose one. What have you booked? Mizaj consultationFull health protocol Please choose one. What did the mizaj quiz give you? Damawi (sanguine) Safrawi (choleric) Sawdawi (melancholic) Balghami (phlegmatic) Not taken it yet Haven't taken it? Take the free quiz in a new tab, then come back. Please choose one. Your healthWhat's going on What are your main health concerns?Please tell me a little about this. How long have you had them?Please answer this one. What would you most like to change in the next 3 months?Please answer this one. Any diagnosed conditions? Write "none" if not.Please answer, even if it's "none". Current medications Write "none" if not.Please answer, even if it's "none". Supplements you take Write "none" if not.Please answer, even if it's "none". Are you pregnant, breastfeeding or trying to conceive? No Pregnant Breastfeeding Trying to conceive Please choose one. Any recent blood tests? Optional. You can bring them to the call. Daily lifeHow you live day to day What do you usually eat for breakfast, lunch and dinner? Meat, vegetables, fruit, nuts, dairy, bread, cakes etc.Please answer this one. How much water do you drink a day? Do you prefer hot or cold drinks? HotColdNo preference Please choose one. Which weather do you prefer? WarmCoolEither Please choose one. What exercise do you do, how often and for how long?Please answer, even if it's "none". How do you sleep? Bedtime, wake time, and whether it's interrupted and why.Please answer this one. Which emotions do you struggle with most? Anger, worry, low mood, fear, grief, restlessness etc.Please answer this one. How often do you open your bowels, and are stools soft or hard? How often do you urinate?Please answer this one. Your monthly cycle How many days, heavy or light, any clots or pain.Please answer this one. Last stepConsent I understand Fitrah Health offers wellness education, not medical advice or treatment, and I'll keep my GP informed about my health.Please tick to continue. I consent to Fitrah Health storing my health information securely to prepare my consultation and protocol. It's never shared.Please tick to continue. Something went wrong sending your form. Please try again, or email your answers to fitrahjournal@gmail.com. Back Next Received JazakAllahu khayran I've got your answers and I'll read them before we speak. See you on the call, in sha Allah.
