New client Questionnaire How did you learn about me? Type your name Date Main health concerns / conditions Health history (timeline, vaccines, illnesses, trauma & dates) Current medications and/or supplements ‘Out of range’ medical test results Illnesses in your immediate family Movement / exercise & frequency Sleep (hours per day & quality) Therapies, diets, supplements, meds that have worked well Therapies, diets, supplements, meds that haven’t worked well Typical Meals & Beverages Breakfast Mid-morning Snack Lunch Mid-afternoon Snack Dinner Evening Snack Beverages Health Issues & Life Experiences Symptons / Conditions AcneAddiction – alcoholAddiction – other substancesAllergies – other than foodAnemiaAnxietyArthritis – osteoArthritis – rheumatoidAsthmaBipolar disorderBladder infectionsBloatingBlood pressure – lowBlood pressure – highBrain fogBronchitisBruising – easyBursitisCataractsCholesterol – highColitisConstipationCoughDepressionDermatitisDiabetesDizzinessEczemaFatigueFearGall stonesGoutHair lossHeadaches – migraineHeadaches – sinusHeartburnHypoglycemiaHypothyroidismJoint painKidney infectionsLearning disabilityMemory – poorMood swingsMuscle – crampsMuscle – painObsessive / CompulsivePanic attacksPsoriasisSleep – insomniaSinus – congestionStomach painSugar reactionsWeight – tend to gainWeight – tend to lose Men: ImpotenceProstate problems Women: Breasts – fibrocysticCrampsHot FlashesMenstruation – heavyMenstruation – irregularMenopauseYeast infection Trauma: Abuse – emotionalAbuse – physicalAbuse – sexual Comments I have read and accept the Privacy Policy
