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?
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