Client Questionnaire by rod 10 January 2011A 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 earlyName* First Last DOB:* DD MM YYYYAddress Street Address Address Line 2 City State Zip Code Phone Number: Work or HomePhone Number: MobileEmail:* Occupation:Relationship Status:SingleMarriedDe FactoChildrenYesNoHow Many Children:Children Ages:Please comma seperate if more than one childHow Did You Find Us:AdvertismentGoogle SearchReferralYellow PagesPyrrole Australia FBSearch Term:Health Fund:EMERGENCY CONTACT - Note, this is a legal requirementName First Last Phone:Relationship To You:Doctor Contact Name:Doctor Contact Phone:MEDICAL / GENERAL HEALTH HISTORYCurrent 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? NoYesIf YES, state type: Hepatitis A, B or C HIV/AIDS OtherMedication (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 Date Format: DD slash MM slash YYYY Please Rate The Following:Daily energy level:ExcellentGoodFairPoorEnergy level after exercise:ExcellentGoodFairPoorDaily stress level:Very HighHighModerateLowNoneDo you have a support system of family and friends?YesNoGeneral enjoyment of life:ExcellentGoodFairPoorIf you experience pain how would you score it (1-10 ten being the worst)?12345678910Sleep Quality:How many hours do you sleep?Please enter a number from 0 to 24.Do you sleep right throughout the night?YesNoDo you wake up without an alarm?YesNoDo you wake up feeling rested?YesNoDo you fall asleep within 15 minutes of retiring?YesNoBowels:Do you have daily regular bowel movements?YesNoHow often do you have a bowel movement?< than once a dayOnce a dayTwice a day> than twice a dayAre your bowel movements:Firm and formConstipatedDiarrheaVariesDo you get bloated or have lots of gas?YesNoAny History Of: Polyps Diverticulitis IBS IBD’sDiet:Please give examples of what you may eat in a typical weekBreakfast: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:YesNoDo you take recreational drugs: (kept confidential)YesNoOn the following, please choose any condition that you currently have or that you feel is important previous historyKP 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 deficienciesU-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, inositolO 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, garlicG 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 conditionWomen please click all that pertain: PMS Frequent urination Irregular periods Painful periods Loss of periods Loss of libido Menopausal Painful intercourse HysterectomyMen please highlight all that pertain: Frequent urination Difficulty with erection Loss of libido Prostate enlargementFamily Medical History: Please list any family illnesses etcPlease list any family illnesses etcIf there is anything else you may wish to add to help me help you then please use this space: This iframe contains the logic required to handle Ajax powered Gravity Forms.
