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

 

Dr. Denice Moffat, Naturopath & Medical Intuitive
Telephone Consultation Services
(208) 877-1222  (Pacific Time)
(208) 877-1969 Consult line

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