Confidential health questionnaireAll of your personal and health information will remain strictly confidential Name * First Name Last Name Email * Phone * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Marital status * Date of birth * Place of birth * Height and current weight * Would you like your weight to be different? If so, how? * Do you have any children? If so, how many? * Occupation. How many hours do you work per week? * What are your main hobbies? How much time do you devote per week? * What are your main health concerns? * What would you like to accomplish from this consultation? * How many hours do you sleep per day? * Do you wake up during the night? If so, at what time(s)? * How do you feel when you wake up in the morning? * Do you drink caffeine? How much and how often? * Do you currently smoke? * Yes No If you smoked in the past, when and why did you quit? * Do you drink alcohol? How much and how often? * Do you drink soda? Diet or regular? How much and how often? * Do you exercise regularly? What do you do and how many hours per week? * Have you been exposed to toxic substances at home or at work? * Do you have any allergies? * Are you currently taking any vitamins/ minerals/ herbs/ homeopathics, prescription medications or OTC aspirin, laxative, diet pills or other supplements? Please list ALL including brands and amounts. * Are you currently under a practitioners care for any health issues? If so, what treatments are you undergoing? * Please list any surgeries, accidents, injuries or childhood diseases you have had along with type and approximate date: * What were your eating habits as a child? * What percentage of your food is home cooked? How much do you eat out? * What are the three healthiest foods you eat each week? * Do you crave sugar? Do you crave salt? * Do you feel tired, bloated and or gassy after meals? * Do you experience diarrhea or constipation often? If so, when and how often? * Do you feel exessively hungry? Do you have a poor appetite? * Family health history * Please check all that apply Diabetes Heart disease Kidney disease Arthritis Asthma Gallbladder disease Cancer Stomach/ Intestinal disease Other How old is your mother? If deceased, how old was she and what was the cause? * How old is your father? If deceased, how old was he and what was the cause? * How old is your maternal grandmother? If deceased, how old was she and what was the cause? * How old is your maternal grandfather? If deceased, how old was he and what was the cause? * How old is your paternal grandmother? If deceased, how old was she and what was the cause? * How old is your paternal grandfather? If deceased, how old was he and what was the cause? * Thank you!
