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Client Questionnaire

by rod 10 January 2011

A copy of this report will be emailed to you when submitted. If not received, please check your spam folder.

Please fill out the client history questionnaire form below prior to your appointment: Please ensure that you click the SUBMIT button at the end and at no time press the enter key or the form will submit too early

Name*
First Last
DOB:*
Day
Month
Year
Address
Street Address Address Line 2 City State Zip Code
Phone Number: Work or Home
Phone Number: Mobile
Email:*
Occupation:
Relationship Status:
Children
- Yes
- No
How Many Children:
Children Ages:
Please comma seperate if more than one child
How Did You Find Us:
Search Term:
Health Fund:
EMERGENCY CONTACT - Note, this is a legal requirement
Name
First Last
Phone:
Relationship To You:
Doctor Contact Name:
Doctor Contact Phone:
MEDICAL / GENERAL HEALTH HISTORY
Current Symptoms & When Did They Start:
General Health History (e.g. list any major physical /emotional / mental incidents, allergies, disease or illness and when they occurred):
List Any Surgical Procedures You Have Had:
Do you have or have you ever had Hepatitis A, B or C, HIV/AIDS or any other infectious disease?
- No
- Yes
If YES, state type:
- Hepatitis A, B or C
- HIV/AIDS
- Other
Medication (list all medication you are currently on – prescribed or otherwise):
Supplements (list any nutritional or herbal products you are taking): Also list any that you have that you are not taking that you may be able to use.
I consent to the modalities and services offered at this clinic (details on website), your name here informs your consent (legal requirment):
First Last
Date
DD slash MM slash YYYY
Please Rate The Following:
Daily energy level:
- Excellent
- Good
- Fair
- Poor
Energy level after exercise:
- Excellent
- Good
- Fair
- Poor
Daily stress level:
- Very High
- High
- Moderate
- Low
- None
Do you have a support system of family and friends?
- Yes
- No
General enjoyment of life:
- Excellent
- Good
- Fair
- Poor
If you experience pain how would you score it (1-10 ten being the worst)?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Sleep Quality:
How many hours do you sleep?
Please enter a number from 0 to 24.
Do you sleep right throughout the night?
- Yes
- No
Do you wake up without an alarm?
- Yes
- No
Do you wake up feeling rested?
- Yes
- No
Do you fall asleep within 15 minutes of retiring?
- Yes
- No
Bowels:
Do you have daily regular bowel movements?
- Yes
- No
How often do you have a bowel movement?
- < than once a day
- Once a day
- Twice a day
- > than twice a day
Are your bowel movements:
- Firm and form
- Constipated
- Diarrhea
- Varies
Do you get bloated or have lots of gas?
- Yes
- No
Any History Of:
- Polyps
- Diverticulitis
- IBS
- IBD’s
Diet:
Please give examples of what you may eat in a typical week
Breakfast:
Mid-morning:
Lunch:
Mid-afternoon:
Dinner:
Snacks:
Junk foods:
Alcohol consumption per week: (standard drinks)
Tea or Coffee consumption per day added (herbal not counted):
Soft drinks consumption per week:
Glasses of water consumed per day:
Do you smoke cigarettes:
- Yes
- No
Do you take recreational drugs: (kept confidential)
- Yes
- No
On the following, please choose any condition that you currently have or that you feel is important previous history
KP screen
- Moodiness/mood swings
- Depression
- Anxiety
- History of aggressive feelings/anger outburst
- Racing mind
- Poor ability to tolerate stress
- Night person / insomnia / sleep problems
- Poor dream recall or recall of vivid bizarre dreams only
- Poor morning appetite, tendency to skip breakfast
- Morning nausea (not pregnant)
- Morning sickness during pregnancy
- React unfavorably to the ‘pill’ or other HRT
- Poor or deteriorating short term memory
- Sensitivity to bright lights, or loud noises, startle easily
- Sensitivity to tags on clothing &/or textures of clothing such as wool
- Unstable blood sugars/carbohydrate craving/hypoglycemia
- White spots on fingernails, brittle weak nails
- Cold hands/feet
- Weight issues
- Sensitive to alcohol
- Get sick easily / or seem to ‘catch’ everything
- Often have vitamin deficiencies
U-M screen
- Seasonal inhalant allergies
- High academic achievement
- Obsessive tendencies/Ritualistic
- Prefer vegetarian food
- Strong willed
- Calm demeanor but high inner tension
- Addictions or addictive personality
- Poor concentration endurance
- History of low calcium, magnesium, B6
- Respond well to SAMe, St. Johns Wort, Kava Kava, inositol
O M screen
- Chemical or food sensitivities
- High anxiety evident to others
- Poor organizational capacity
- Underachievement at school
- Poor sleep
- Panic attacks
- Racing thoughts
- Low libido
- Heavy body hair
- Hyperactive
- Nervous legs
- Any known adverse reactions to Prozac, Paxil, Zoloft, St.John’s Wort or SAMe products
- Tendency to have low levels of folic acid, B3 (niacin), B12
- Reaction to sulphur foods—onions, garlic
G screen
- History of kidney stones
- Liver problems
- Gall bladder problems
- Bladder infections (Cystitis)
- Hair loss or poor hair growth
- Headaches/migraines
- Respiratory problems
- Cancer
- Heartburn
- Hemorrhoids
- Cold Sores
- High blood pressure
- High cholesterol
- Dandruff
- Thyroid condition
Women please click all that pertain:
- PMS
- Frequent urination
- Irregular periods
- Painful periods
- Loss of periods
- Loss of libido
- Menopausal
- Painful intercourse
- Hysterectomy
Men please highlight all that pertain:
- Frequent urination
- Difficulty with erection
- Loss of libido
- Prostate enlargement
Family Medical History: Please list any family illnesses etc
Please list any family illnesses etc
If there is anything else you may wish to add to help me help you then please use this space:
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