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Root Path · Application

Before we talk, tell me about you.

This questionnaire helps me arrive at our first conversation already knowing you. It takes about 25 minutes. Answer what you can, and leave blank what you don’t know.

About you

First name *

Last name *

Email *

Phone / WhatsApp (with country code) *

Country *

City

Time zone

Age *

Sex *

FemaleMalePrefer not to say

Height

Weight

Language for our sessions

EnglishSpanish

Name you use on Zoom

How did you hear about me?

InstagramA friend or family memberGoogle or the webI already knew youOther

Why this path

There are no right answers. Write as much or as little as feels true.

What brings you here? Tick all that apply.

Tiredness or low energyStress, anxiety or nervesLow mood or sadnessSleepDigestionPainHormones or cycleSkinWeightA diagnosisRelationships or familyA pattern that keeps repeatingOther

In your own words (optional)

Why now?

Symptoms got worseI received a diagnosisA change or hard moment in my lifeI’m tired of what hasn’t workedSomeone recommended youOther

What do you hope will change? Tick all that apply.

More energyBetter sleepCalmer digestionLess painEmotional calmUnderstanding the rootHabits that lastSupport during a treatmentOther

What have you already tried?

Conventional medicineMedicationSupplementsChanges in dietDetox or cleansesPsychological therapyAcupuncture or Chinese medicineHomeopathyNothing yet

Anything you’d like me to know before we talk?

Diagnosis and medical care

This helps me see which path is right for you now. Nothing here decides anything without our conversation.

Your diagnosis or diagnoses, and when they were given *

Are you currently in chemotherapy? *

YesNoFinished

If finished, when, and how many cycles?

Are you receiving immunotherapy or taking immunosuppressants? (e.g. methotrexate, azathioprine, biologics, high-dose corticosteroids) *

YesNoNot sure

Radiotherapy

NowIn the pastNever

Hormone therapy (e.g. tamoxifen, aromatase inhibitors)

NowIn the pastNever

Any surgery recent or planned?

NoRecentPlanned

Have any lymph nodes or organs been removed? Where, and how many?

Your main doctor or oncologist (name and place) *

Does your doctor know you are looking for complementary support? *

YesNot yetI’d like to talk about it first

Your weight in the last 3–6 months *

StableLost without tryingGained

If it changed, roughly how much?

Less than 2 kg2–5 kg5–10 kgMore than 10 kg

Appetite

GoodReducedVery low

Medication and supplements

Medication you take now: name, dose and since when

Supplements, herbs or remedies you take now

Have you followed an herbal detox program before (such as Dr. Morse’s formulas)?

CurrentlyIn the pastNever

Glandulars (natural gland extracts) are sometimes suggested to support a specific area. How do you feel about them?

Open to themPrefer notNot sure

Allergies or intolerances

None knownGlutenDairyOther foodsMedicationPollen, dust or animalsOther

Vitals

Optional. If you don’t know a reading, leave it blank.

Blood pressure, right arm

Blood pressure, left arm

Resting pulse (bpm)

Temperature on waking (°C or °F)

Urine pH

Saliva pH

Oxygen saturation (SpO2 %)

Eye colour

BrownBlueGreenHazel / mixedGrey

Daily life

Please be as honest as you can. This is not a test.

Breakfast, usually

Lunch

Dinner

Snacks and drinks between meals

How much water do you drink a day?

Less than 1 litre1–1.5 litres1.5–2 litresMore than 2 litres

Alcohol

NeverMonthlyWeeklyDaily

Do you smoke?

NoIn the pastYes

If yes, how much a day?

Fewer than 55–1010–20More than 20

Recreational drugs (confidential)

NeverIn the pastNowPrefer not to say

Hours of sleep a night

Less than 55–66–77–8More than 8

Movement or exercise in a normal week

Almost none1–2 times3–4 times5 or more

Bowel movements a day *

0–1234 or more

Coating on your tongue on waking

NoneWhiteYellowGreenBrown

How much do you sweat?

LittleNormalA lot

Body check

Tap Now, Past or Both for anything that applies. Leave the rest untouched. Tap again to clear.

Thyroid and glands

Cold hands or feet

NowPastBoth

Always cold, hard to warm up

NowPastBoth

Cold outside, burning inside

NowPastBoth

Gain weight easily, hard to lose it

NowPastBoth

Low energy, always tired

NowPastBoth

Irregular heartbeat

NowPastBoth

Headaches or migraines

NowPastBoth

Easily irritable

NowPastBoth

Weak, brittle or ridged nails

NowPastBoth

Goiter, Hashimoto’s or Graves’

NowPastBoth

Thyroid condition in the family

NowPastBoth

Adrenals and nervous system

Anxiety

NowPastBoth

Excessive shyness or low self-worth

NowPastBoth

Tremors or restless legs

NowPastBoth

High blood pressure

NowPastBoth

Low blood pressure

NowPastBoth

Low blood sugar

NowPastBoth

Diabetes type 1

NowPastBoth

Diabetes type 2

NowPastBoth

Ringing in the ears

NowPastBoth

Hard to take a deep breath

NowPastBoth

Hard to fall asleep

NowPastBoth

Hard to stay asleep

NowPastBoth

Joint inflammation (arthritis, bursitis…)

NowPastBoth

Low cortisol

NowPastBoth

ADD / ADHD

NowPastBoth

Neurological condition (MS, Parkinson’s, ALS…)

NowPastBoth

Mental health challenges (depression, PTSD, OCD…), if any

Digestion, liver and pancreas

Slow digestion

NowPastBoth

Diarrhoea

NowPastBoth

Constipation

NowPastBoth

Reflux, heartburn or indigestion

NowPastBoth

Undigested food in stool

NowPastBoth

Gas or bloating

NowPastBoth

Hard to digest fats or dairy

NowPastBoth

Light or pale stools

NowPastBoth

Mid-back pain after eating

NowPastBoth

Liver spots (not freckles)

NowPastBoth

Thin, hard to gain weight

NowPastBoth

Anaemia

NowPastBoth

Hepatitis

NowPastBoth

Crohn’s, colitis, gastritis or diverticulitis

NowPastBoth

Stomach or intestinal ulcers

NowPastBoth

Other digestive issues

Heart and circulation

Varicose or spider veins

NowPastBoth

Haemorrhoids or prolapse

NowPastBoth

Muscle cramps

NowPastBoth

Legs tire easily

NowPastBoth

Bruise easily

NowPastBoth

Chest pain or pressure

NowPastBoth

Heart attack, stents or pacemaker

NowPastBoth

Hernia or aneurysm

NowPastBoth

Lymph and immunity

Swollen lymph nodes

NowPastBoth

Lymphoedema

NowPastBoth

Fluid retention

NowPastBoth

Frequent colds or flu-like symptoms

NowPastBoth

Sore throat

NowPastBoth

Sinus problems

NowPastBoth

Brain fog, poor memory

NowPastBoth

Mucus in the eyes on waking

NowPastBoth

Blurred vision

NowPastBoth

Fibromyalgia

NowPastBoth

Scleroderma

NowPastBoth

Low platelets

NowPastBoth

Boils, cysts or abscesses

NowPastBoth

Tonsils removed

NowPastBoth

Appendix removed

NowPastBoth

Snoring or sleep apnoea

NowPastBoth

Kidneys and bladder

Urinary infections or cystitis

NowPastBoth

Burning when urinating

NowPastBoth

Weak bladder, incontinence

NowPastBoth

Restricted urine flow

NowPastBoth

Kidney stones

NowPastBoth

Pain mid to lower back, either side

NowPastBoth

Lower back weakness

NowPastBoth

Sciatica

NowPastBoth

Bags under the eyes

NowPastBoth

Gout

NowPastBoth

Lungs

Asthma

NowPastBoth

Bronchitis or pneumonia

NowPastBoth

COPD or emphysema

NowPastBoth

Frequent cough

NowPastBoth

Pain or difficulty breathing

NowPastBoth

Use an inhaler or nebuliser

NowPastBoth

Skin and hair

Acne, rashes or blemishes

NowPastBoth

Eczema, dermatitis or psoriasis

NowPastBoth

Dry, itchy skin

NowPastBoth

Very oily skin

NowPastBoth

Dandruff

NowPastBoth

Hair loss

NowPastBoth

Changes in skin pigmentation

NowPastBoth

Tattoos

NowPastBoth

Bones and structure

Low bone density or osteoporosis

NowPastBoth

Scoliosis, kyphosis or lordosis

NowPastBoth

Herniated discs or spinal wear

NowPastBoth

Bone spurs

NowPastBoth

Women

Pregnant

NowPastBoth

Breastfeeding

NowPastBoth

Irregular cycle

NowPastBoth

Heavy bleeding

NowPastBoth

Sore or painful breasts

NowPastBoth

Fibrocystic breasts

NowPastBoth

Ovarian cysts or fibroids

NowPastBoth

Endometriosis or atypical cells

NowPastBoth

Difficulty conceiving

NowPastBoth

Menopause or perimenopause

NowPastBoth

Hysterectomy (partial or complete)

NowPastBoth

Low sex drive

NowPastBoth

Birth control pill

NowPastBoth

If you take or took the pill, for how long?

Men

Prostatitis

NowPastBoth

Prostate diagnosis

NowPastBoth

Erection difficulties

NowPastBoth

Premature ejaculation

NowPastBoth

Enlarged testicles

NowPastBoth

Low sex drive

NowPastBoth

Waking at night to urinate

NowPastBoth

Last PSA, if you know it

Your history

Surgeries, minor or major, with the year

Known health conditions in your family. Leave blank if you’re not sure.

Mother

Father

Maternal grandparents

Paternal grandparents

Brothers and sisters

Have you been exposed to…

Heavy metalsToxic chemicals or pesticidesMould or damp housingAsbestos or minesRadiationAmalgam (silver) fillingsAntennas or power lines near home or work

Anything else about your home or work environment?

Your inner world

Take your time here. Answer only what you feel ready to share.

Your stress level right now, from 0 to 10

012345678910

What weighs on you most right now?

What was happening in your life in the one to three years before your symptoms or diagnosis?

Losses, separations or hard moments that still feel present

Feelings you have carried for a long time without much space to express them

How supported do you feel at home?

Very supportedSomewhatA littleNot at all

How do you feel about your body right now?

At peaceNeutralIt’s hardVery hard

Is faith or spirituality part of your life?

Yes, very muchSomewhatNot really

Would you like it to be part of our work?

YesMaybeNo

What gives you strength?

If this process goes well, what would you like your life to hold?

Almost done

Best times for our conversation (in your time zone)

Weekday morningsWeekday afternoonsWeekday eveningsWeekendsAny time

How would you like to meet?

OnlineIn person, if possibleEither

I understand this is complementary work. It does not diagnose, treat or cure illness and does not replace my doctors or medical treatment.I will stay under medical care and let you know if my treatment changes.What I’ve shared is true to the best of my knowledge.I agree that my answers are used only to prepare our work together, as described in the privacy notice.

Your answers could not be sent just now. Your progress is saved: please try again in a few minutes, or write to me at johanna@thenaturalismethod.com.

Your progress is saved on this device. Answers come only to me.

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