NOTE: Please do not send me this list ahead of time. I’m all color-coded on this end. I’ll ask some of these questions during the consult. This questionnaire is just a memory jogger for you.

• Client:
• Patient:
• Address:
• City/State/Zip
• Phone (Home)
• Phone (Alt.)
• e-mail:
• Best way and time to reach you:
• How did you hear of us?
• List all supplements/medications you are taking  (You may do this on the To Do List)
• Religion:
• How do you best learn?
• Reading  Listening  Hands on  Combination  Other:
• Do you work best with outlines or details?
• Who is on your team of healers?
• (Please list doctors, chiropractors, massage therapists, naturopaths, etc.)
• OK to release info to them if helpful? Yes/No
• History and Concerns:
• Species/Breed (Animals)
• Color/Nationality (Humans)
• Blood Type:    Type O      Type A      Type AB    Type B
• Intact/Neutered/Spayed/Partial/Tubal/Full
• Sex:
• If Female, are you on hormone replacement therapy? Which kind?
• DOB:
• Weight:
• Diet:
• Breakfast foods:
• Lunch Foods:
• Dinner Foods:
• Snack Foods:
• Favorite restaurants:
• Cravings:
• Favorite Foods:
• Carbohydrates
• Proteins
• Oils/Fats
• What Fruits do you eat?
• How many half-cup servings of raw fruits do you eat/day on the average?
• What Vegetables do you eat?
• How many half-cup servings of raw vegetables do you eat/day on the average?
• Vegetables, Raw ___________ Cooked _____________
• BM’s/day:
• Constipation/Diarrhea/Mucous/Blood/Normal
• Hrs. Sleep/Night:                 Rested? Yes/No
• Do you wake up during the night? If so, at what time?
• How many times do you get up to urinate during the sleep cycle?
• Type Night Clothes
• Electric Blankets
• Exercise Freq.:                    Type:
• Shoe Wear Left Foot:
• Shoe Wear Right Foot:
• Weight Carriage (Where do you hold your weight?):
• Heart Rate:
• Blood Pressure:
• Complexion:
• # Cups Water/day:             Type:
• City Tap  Bottled  Well  Distilled Filtered: ________________
• How can I best support you?
•     Phone    email   Accountability   Reminder Cards
•     Support Group   Mailing Appropriate Material
•     Re-Check Appts.   To Do Lists   Check off Boxes
•     Handouts   Keep it Simple   Work with my Team
•     Examples/Stories to clarify   Other:
• Please list dis-eases/problems/concerns/fears you have had in the past or currently have.
• I would also like to know if these problems are familial in nature.
• Below is a partial list of areas of the body to trigger your memory:
• Brain
• Head
• Ears
• Senses
• Eyes
• Nervous system
• Hormones
• Reproductive
• Immune system
• Emotional challenges
• Stresses
• Skin/Hair/Nails
• Muscles
• Bruising
• Skeletal problems
• Aches/Pains of any kind
• Energy levels
• Digestive disorders
• Respiratory System
• What vaccinations have you had?
• Have you ever traveled out of the country?
• Where have you lived?
• What jobs have you performed in your life?
• Circulation challenges
• Abnormal tests received from the doctor
• Challenges that the medical profession has not been able to help
• Challenges that you never mentioned because you thought they were just a part of you.
• Urinary system
• Elimination problems
• Allergies
• Yeast infections
• What childhood diseases have you had?
• Learning difficulties
• Parasite problems
• Drug reactions
• Near Death Experiences
• Depression
• Breast implants or other implants
• What scars do you have and where are they?
• Have you had any genetic screening?
• Please list anything I may have missed that you would like to address
• What are your top three concerns?
• 1
• 2
• 3