Holistic Health Intake Consultation Note

Primary Health Goals

• Reduce bilateral wrist pain to improve typing endurance
• Improve sleep quality and duration
• Establish a sustainable daily routine to manage work-related stress
• Increase afternoon energy levels

Health History

Pre-diagnosed illnesses and diseases

Medical Diagnosis

1: Bilateral carpal tunnel syndrome, active, 2023 2: Generalized anxiety disorder (GAD), managed, 2021 3: Gastroesophageal reflux disease (GERD), intermittent, 2020 4: Vitamin D deficiency, resolved, 2022

Current Supplements

• Ergocalciferol (vitamin D2) 50 mcg PO daily

Prescription Medications

• Escitalopram (Lexapro®) 10 mg PO daily
• Omeprazole (Prilosec®) 20 mg PO daily PRN

Allergies

• Penicillin (rash)

Medical History Notes

• Pt works remotely as a software developer; high daily keyboard use exacerbates wrist paraesthesia.
• Hx of sporadic physical therapy for wrist pain; struggles with home exercise program (HEP) adherence due to fatigue.
• Reports chronic tension headaches 2x/wk, typically late afternoon.

Lifestyle & Diet

Diet

Are there any foods you avoid? - Spicy foods, heavy dairy, and tomato-based sauces due to GERD

Have you ever followed a weight-loss diet? - Keto diet in 2019 for 3 mos; discontinued due to difficulty maintaining

Do you use intermittent fasting? - 16:8 protocol sporadically, skips breakfast on workdays

What are your favorite foods? - Sushi, roasted vegetables, dark chocolate, pasta

Do you experience any symptoms after meals? - Mild bloating and postprandial somnolence after high-carb lunches

Diet Routine

• Skips breakfast most weekdays; drinks coffee on an empty stomach.
• Tends to eat lunch at ergonomic desk while continuing to work.
• Relies on takeout 3-4 nights/wk due to evening fatigue and wrist pain limiting meal prep.
• Late-night snacking while watching TV around 22:00.

Breakfast - Black coffee only on weekdays; scrambled eggs and toast on weekends Lunch - Deli turkey sandwich with chips, or leftover takeout Dinner - Stir-fry, pasta, or ordered Thai food Snacks/Sweets - Mixed nuts, pretzels, dark chocolate squares in the evening

Beverages -

How much water do you drink daily? - Approx 1.2 L

Do you consume caffeinated beverages? - 3 cups (approx 750 mL) drip coffee daily between 07:30 and 14:00

Do you consume alcohol? - 2-3 craft beers on weekends

List any other drinks you consume

- Flavored sparkling water (1-2 cans/day), chamomile tea occasionally

Stress/Sleep

Stress Patterns

What level of stress are you currently experiencing? - High (7/10)

List your main stressors

- Tight project deadlines at work, fear of worsening wrist function, financial planning

What helps you decompress? - Listening to audiobooks, walking the dog, warm showers

Sleep Patterns

How many hours do you sleep at night? - 5.5 to 6 hrs (typically 00:30 to 06:30)

Do you have good quality sleep? - Poor; wakes up 2-3x/night with racing thoughts or numb hands

Do you wake feeling rested? - No, feels groggy and relies heavily on caffeine to start the day

Exercise

How often do you exercise? - 2-3x/wk

What types of exercise do you do? - 30 min neighborhood walks; avoids weightlifting and yoga due to wrist weight-bearing intolerance

Additional Notes

How many hours per week do you use a computer? - 45-50 hrs/wk

How many hours per day do you use a smart phone? - 3.5 hrs/day

Do you or have you used recreational drugs? - Cannabis gummies occasionally on weekends for sleep

Do you use nicotine products? - Yes

If yes, what kind? - Nicotine pouches (3 mg), 2-3x/day while working

Action Plan

Nutrition

• Increase water intake to 2 L/day; keep a filled 1 L bottle at workstation.
• Consume a protein-rich breakfast (e.g., Greek yogurt or pre-made protein shake) prior to first cup of coffee to stabilize morning cortisol and reduce GI irritation.
• Utilize pre-chopped vegetables and rotisserie chicken to minimize knife work and wrist strain during meal prep.
• Cease caffeine intake by 12:00 and avoid food within 3 hrs of bedtime to minimize nocturnal GERD and sleep disruption.

Exercise

• Incorporate 2 min micro-breaks every 45 mins of computer work for tendon gliding exercises and cervical stretches.
• Increase brisk walking to 30 mins 5x/wk during lunch breaks, stepping away from the workstation.

Stress/Sleep

• Implement a strict digital sunset at 22:30 (no screens) to reduce blue light exposure and mental stimulation.
• Wear bilateral neutral wrist splints at night to prevent nocturnal flexion and waking from paraesthesia.
• Practice 10 mins of box breathing or progressive muscle relaxation in bed prior to sleep.

Supplements

• Continue ergocalciferol (vitamin D2) 50 mcg PO daily with breakfast.
• Initiate magnesium glycinate 200 mg PO daily 1 hr before bed to support sleep quality and muscle relaxation.

Miscellaneous

• Complete an ergonomic workstation self-assessment; transition to a vertical mouse and split ergonomic keyboard within 2 wks.
• Use voice-to-text software on smartphone and computer when possible to offload upper extremity repetitive strain.

Follow-up

Return in 4 wks (15/04/2026 at 10:00) to review ergonomic modifications, sleep log, and symptom progression.