Name:
Date:
Age:
Please answer each of the following questions.
What are your main health concerns/complaints?
Do you wish to gain weight?
Lose weight?
If so, how much?
What level of stress do you feel you are experiencing right now?
minimal
average
considerable
unbearable
What are the major causes of your stress?
Financial
Career
Personal
Marriage
Health
Family
Spiritual
Unfulfilled expectations
Other (Please elaborate)
How many hours do you sleep on daily? (average, include naps)
What time do you go to sleep?
Awaken?
Do you awaken feeling rested?
yes
no
What type of work do you do?
Do you enjoy your work?
yes
no
sometimes
How many hours each day do you work?
Start time and end time?
Do you smoke?
yes
no If yes, how much?
Does anyone else in your household smoke?
yes
no
What do you do for exercise?
how often?
How many hours a day do you
watch television?
read?
spend on a computer?
What are your interests and hobbies?
Medical History:
Are you currently taking any medications?
yes
no
List/Reasons:
Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosages?
Do you have any allergies? If so, please list:
Have you ever been diagnosed with an illness
Explain:
Been hospitalized?
For what reason?
How often do you have a bowel movement?
Do you strain to have a bowel movement?
Family History:
Hereditary diseases: Please check off “F” for Father, “M” for Mother, “S” for siblings.
“G” for grandparents, “O” for other relatives.
heart disease
Diabetes
Allergies
Hypertension
Arthritis
Mental Illness
Cancer
Osteoporosis
Intestinal Disease
Other: (Please list)
Have you ever been treated for drug and/or alcohol dependency?
yes
no
Dietary Habits
How many times a day do you eat:
Main meals
Times of day:
Snacks
Times of day:
Please list what you typically eat for:
Breakfast
Lunch
Dinner
Snacks
At what time do you have your last meal or snack of the day?
Do you eat or use:
fried foods
refined foods
candy
microwave
luncheon meats
cigarettes
aluminum pans
margarine
Nutra-Sweet/Aspartame
fast foods
Please indicate how many cups of the following you drink per day:
beer
red wine
coffee
white wine
tap water
other alcoholic beverage
soft drinks (diet)
soft drinks (regular)
tea
fresh fruit juices
milk (2%)
milk (skim)
fruit juice (bottled)
bottled or spring water
fresh vegetable juices
other
Are you:
A meat eater?
Vegetarian?
Vegan?
How often do you eat meat?
daily
3-5/week
once/week or less
If you are vegetarian, how often do you consume dairy products?
Daily
3-5/week
once a week or less
What are your favorite foods?
Do you avoid certain foods? If so, why?
Do you experience any symptoms after meals? Explain
Comments:
What is your weight?
What is your height?
Client Statement:
I understand and acknowledge that the services hereby provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. I also understand that any information given in a consultation is guaranteed to be held as confidential and private unless agreed to by myself in writing.
This statement is being signed voluntarily.
Date:
Name
Address:
Telephone:
email:
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