Questionaire

Client Questionnaire

by Sharon Barrese C.N.C (Share in Health)
Hello! Please fill out the questionaire to the best of your ability. Once completed and submitted, we will receive a copy of the form and get in contact with you within 3-5 business days.

It is important that all information is accurate in order to assess your health needs. Sharon is then able to able to create a program tailored TO YOU!

Please allow yourself approximately 30 min to fill out the form. Thank you!
HEALTH HISTORY

Page 1
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Occupation
Age
Height
Sex
Number of Children
Marital Status:

SinglePartnerMarriedSeparatedWidow(er)Divorced
Are you recovering from a cold or flu?
Are you pregnant?
Blood Type
Reason for office visit
Date Began

MonthDayYear
Date
Date of last physical exam

MonthDayYear
Date
Practitioner Name
Practitioner's Phone Number
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis) Please, send lab results to Sharon at sharnhealth@yahoo.com, five business days prior to your first appointment.
What types of therapy have you tried for this problem(s):

diet modificationfastingvitamin/mineralherbshomeopathychiropracticacupunctureconventional drugsOther
List current health problems for which you are being treated:
Current medications (prescription or over-the-counter):
Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications (if any) and dates:
Outcome of Operation, Illness, Injury:
Circle the level of stress you are experiencing on a scale of 1 to 10:

12345678910
Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems):
Do you consider yourself:

underweightoverweightjust rightunintentional weight loss or gain of 10 pounds or more in the last three months
Your Weight Today
Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, farmer, miner):
Choose One (if applicable)

Corrective lensesDenturesHearing aid
Medical Devices/prosthetics/implants, describe:
Recent changes in your ability to:

seeheartastesmellfeel hot/cold sensationsmove around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers
Strong LIKE for any of the following flavors:

sourbittersweetrich/fattyspicy/pungentsalty
Strong DISLIKE for any of the following flavors:

sourbittersweetrich/fattyspicy/pungentsalty
Do you:

Prefer warmth (i.e., food, drinks, weather etc.)Prefer cold (i.e., food, drinks, weather etc.)No preference
Is your sleep disturbed at the same time each night?
If yes, what time?
Time of day you feel the most energy or the least symptoms:

7 a.m. - 9 a.m.9 a.m. - 11 a.m.11 a.m. - 1 p.m.1 p.m. - 3 p.m.3 p.m. - 5 p.m.5 p.m. - 7 p.m.7 p.m. - 9 p.m.9 p.m. - 11 p.m.11 p.m. - 1 a.m.1 a.m. - 3 a.m.3 a.m. - 5 a.m.5 a.m. - 7 a.m.
Time of day you feel the worst or your symptoms are aggravated:

7 a.m. - 9 a.m.9 a.m. - 11 a.m.11 a.m. - 1 p.m.1 p.m. - 3 p.m.3 p.m. - 5 p.m.5 p.m. - 7 p.m.7 p.m. - 9 p.m.9 p.m. - 11 p.m.11 p.m. - 1 a.m.1 a.m. - 3 a.m.3 a.m. - 5 a.m.5 a.m. - 7 a.m.
Do you experience any of these general symptoms EVERYDAY?

Debilitating fatigueShortness of breathInsomniaConstipationChronic pain/inflammationBleedingDepressionNauseaPanic attacksBleedingHeadachesDisinterest in sexVomitingUrinary incontinenceDischargeDisinterest in eatingDizzinessDiarrheaLow grade feverDisinterest in eatingFecal incontinenceItching/rash
Medical History

Page 2
Medical History

ArthritisAllergies/hayfeverAsthmaAlcoholismAlzheimer's diseaseAutoimmune diseaseBlood pressure problemsBronchitisCancerChronic fatigue syndromeCarpal tunnel syndromeCholesterol, elevatedCirculatory problemsColitisDental problemsDepressionDiabetesDiverticular diseaseDrug addictionEating disorderEpilepsyEmphysemaEyes, ears, nose, throat problemsEnvironmental sensitivitiesFibromyalgiaFood intoleranceGastroesophageal reflux diseaseGenetic disorderGlaucomaGoutHeart DiseaseInfection, chronicInflammatory bowel diseaseIrritable bowel syndromeKidney or bladder diseaseLearning disabilitiesLiver or gallbladder disease (stones)Mental illnessMental retardationMigraine headachesNeurological problems (Parkinson's, paralysis)Sinus problemStrokeThyroid problemObesityOsteoperosisPneumoniaSexually transmitted diseaseSeasonal affective disorderSkin problemsTuberculosisUlcerUrinary tract infectionVaricose veinsOther
Medical (Men)

BPHProstate cancerDecreased sex driveInfertilitySTDOther
Medical (Women)

Menstrual irregularitiesEndometriosisInfertilityFibrocystic breastsFibroids/ovarian cystsPMSBreast cancerPelvic inflammatory diseaseVaginal infectionsDecreased sex driveSTDOther
Age of first period
Date of last gynecological exam

MonthDayYear
Date
Mammogram

+-
PAP

+-
Form of birth control
Number of children
Number of pregnancies
C-section:
Medical (Women continued)

Surgical menopauseMenopause
Date of last menstrual cycle

MonthDayYear
Date
Length of cycle
i.e. how many days
Interval of time between cycles
Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty)
Family Health History (parents and siblings)

Arthritis, rheumatoidAsthmaAlcoholismAlzheimer's diseaseCancerDepressionDiabetesDrug addictionEating disorderGenetic disorderGlaucomaHeart DiseaseInfertilityLearning DisabilitiesMental IllnessMental RetardationMigraine headachesNeurological disorders (Parkinson's paralysis)ObesityOsteoporosisStrokeSuicideOther
Health Habits
Select, if yes:

Tobacco
Cigarettes: #/day
Cigars: #/day
Select, if yes:

Alcohol
Wine: #glasses/d or wk
Liquor: #ounces/d or wk
Beer: #glasses/d or wk
Select, if yes:

Caffeine
Coffee: # of 6oz cups/day
Tea: # of 6oz cups/day
Soda w/caffeine: # of cans/day
Other sources:
Water: # of glasses/day
Exercise
Exercise

5-7 days per week3-4 days per week1-2 days per week45 minutes or more duration per workout30-45 minutes duration per workoutLess than 30 minutesWalkRun, jog, jump ropeWeight liftSwimBoxYoga
Nutrition & Diet
Nutrition & Diet

Mixed food diet (animal and vegetable sourcesVegetarianVeganSalt restrictionFat RestrictionStarch/carbohydrate restrictionThe Zone DietTotal calorie restriction
Specific food restrictions:

dairywheateggssoycornall glutenOther
Food Frequency

Servings per day:
Fruits (citrus, melons, etc.)
Dark green or deep yellow/orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
Eating Habits
Choose, all that apply:

Skip breakfastTwo meal/dayOne meal/dayGraze (small frequent meals)Food rotationEat constantly whether hungry or notGenerally eat on the runAdd salt to food
Current Supplements
Choose, all that apply:

Multivitamin/mineralVitamin CVitamin EEPA/DHAEvening Primrose/GLACalcium, sourceMagnesiumZincMinerals, describeFriendly flora (acidophilus)Digestive enzymesAmino acidsCoQ10Antioxidants (e.g., lutein, resveritrol, etc.)Herbs - teasHerbs - extractsChinese herbsAyurvedic herbsHomeopathyBach flowersProtein shakesSuperfoods (e.g., bee pollen, phytonutrient blends)Liquid meals (e.g., Ensure)Other
Would you like to:

Have more energyBe strongerHave more enduranceIncrease your sex driveBe thinnerBe more muscularImprove your complexionHave stronger nailsHave ehalthier hairBe less moddyBe less depressedBe less indecisiveFell more motivatedBe more organizedThink more clearly and be more focusedImprove memoryDo better on tests in schoolNot be dependent on over-the-counter medications like aspirin, Tylenol, Benadryl, sleeping acids, etc.Stop using laxatives or stool softnersBe free of painSleep betterHave agreeable breathHave agreeable body odorHave stronger teethGet less colds and flusGet rid of your allergiesReduce your risks of inherited disease tendencies (e.g., cancer, heart disease, etc.)
Health Appraisal Questionnaire

Page 3
Name

First NameLast Name
Date

MonthDayYear
Date
Directions

This questionnaire asks you to assess how you have been feeling during the last four months. This information will help to keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity and time spent on personal growth.

All information is held in strict confidence. Take all the time you need to complete this questionnaire.

For each question, circle the number that best describes your symptoms:

0 = No or Rarely - You have never experienced the symptom or symptom is familiar to you but you perceive it as insignificant (monthly or less)
1 = Occasionally - Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
4 = Often - Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently - Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis

Some questions require a YES or NO response. 0 = NO 8 = YES
PART I: Section A

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Indigestion, food repeats on you after you eat
2. Excessive burping, bleaching and/or bloating following meals
3. A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
4. A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
5. Bad taste in your mouth
6. Small amounts of food full you up immediately
7. Skip meals or eat erratically because you have no appetite

Total points from Section A:
PART I: SECTION B

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Strong emotions, or the thoughts or smell of food aggravates your stomach or makes it hurt
2. Feel hungry an hour or two after eating a good-sized meal
3. Stomach pain, burning and/or aching over a period of 1-4 hours after eating
4. Stomach pain, burning and/or aching relieved by eating food, drinking carbonated beverage, cream or milk, or taking antacids
5. Burning sensation in the lower part of your chest, especially when lying down or bending forward
6. Digestive problems subside with rest and relaxation
7. Eating spicy and fatty (friend) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
8. Feel a sense of nausea when you eat
9. Difficulty or pain when swallowing food or beverage

Total points from Section B:
PART I: SECTION C

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. When massaging under your rib cage on your left side, there is pain, tenderness or soreness
2. Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
3. Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
4. Specific foods/beverages aggravate indigestion
5. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
6. Stool odor is embarrassing
7. Undigested food in your stool
8. Three or more large bowel movements daily
9. Diarrhea (frequent loose, watery stool)
10. Bowel movement shortly after eating (within 1 hour)

Total points from Section C:
PART I: Section D

Please fill out and add totals below.

	No/Rarely (0 points)	Occasionally (1 point)	Often (4points)	Frequently (8 points)
1. Discomfort, pain, or cramps in your colon (lower abdominal area)
2. Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
3. Generally constipated (or straining during bowel movements)
4. Stool is small, hard and dry
5. Pass mucous in your stool
6. Alternate between constipation and diarrhea
7. Rectal pain, itching or cramping
8. No urge to have a bowel movement
9. An almost continual need to have a bowel movement

Total points from Section D:
PART II

Please fill out and add totals below.

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. When massaging under your rib cage on your right side, there is pain, tenderness or soreness
2. Abdominal pain worsens with deep breathing
3. Pain at night that may move to your back or right shoulder
4. Bitter fluid repeats after eating
5. Feel abdominal discomfort or nausea when eating rich, fatty or fried foods
6. Throbbing temples and/or dull pain in forehead associated with evereating
7. Unexplained itchy skin worse at night
8. Stool color alternative from clay colored to normal brown
9. General feeling of poor health
10. Aching muscles not due to exercise
11. Retain fluid and feel swollen around the abdominal area
12. Reddened skin, especially palms
13. Very strong body odor
14. Are you embarrassed by your breath?
15. Bruise easily (No [0] or Yes [8])
16. Yellowish cast to eyes (No [0] or Yes [8])

Total points from Part II
PART III: Section A

Page 4

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Feel cold or chilled — hands, feet, all over — for no apparent reason
2. Your upper eyelids look swollen
3. Muscles are weak, cramp and/or tremble
4. Are you forgetful?
5. Do you feel like your heart beats slowly?
6. Reaction time seems slowed down
7. In general, are you disinterested in sex because your desire is low?
8. Feel slow-moving, sluggish
9. Constipation
10. Dryness, discoloration of skin and.or hair (No [0] or Yes [8])
11. Have you noticed recently that your voice is deepening? (No [0] or Yes [8])
12. Thick, brittle nails (No [0] or Yes [8])
13. Weight gain for no apparent reason (No [0] or Yes [8])
14. Outer third of your eyebrow is thinning or disappearing (No [0] or Yes [8])
15. Swelling of the neck (No [0] or Yes [8])

Total points from PART III, Section A:
PART III: Section B

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Lingering mild fatigue after exertion or stress
2. Do you find that you get tired and exhausted very easily?
3. Craving for salty foods
4. Sensitive to minor changes in weather and soundings
5. Dizzy when rising or standing up from a kneeling position
6. Dark bluish or black circles under your eyes
7. Have bouts of nausea with or without vomiting
8. Catch colds or infections easily (No [0] or Yes [8])
9. Wounds heal slowly (No [0] or Yes [8])
10. Your body or parts of your body feel tender, sore, sensitive to the touch, hot and/or painful
11. Feel puffy and swollen all over your body
12. Skin is gradually tanning without exposure to sun or the ingestion of high levels of carotene-rich foods (e.g., daily carrot juice intake or supplements) (No [0] or Yes [8])

Total points from PART III, Section B:
PART IV: Section A

When you miss meals or go without food for extended periods of time, do you experience any of the following symptoms?

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. A sense of weakness
2. A sudden sense of anxiety when you get hungry
3. Tingling sensation in your hands
4. A sensation of your heart beating too quickly or forcefully
5. Shaky, jittery, hands trembling
6. Sudden profuse sweating and/or your skin feels clammy
7. Nightmares possibly associated with going to bed on an empty stomach
8. Wake up at night feeling restless
9. Agitation, easily upset, nervous
10. Poor memory, forgetful
11. Confused or disorientated
12. Dizzy, faint
13. Cold or numb
14. Mild headaches or head pounding
15. Blurred vision or double vision
16. Feel clumsy and uncoordinated

Total points from PART IV, Section A:
PART IV: Section B

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Frequent urination day and night
2. Unusual thirst — feeling like you can't drink enough water
3. Unusual hunger — eating all the time
4. Vision blurs
5. Feel itchy all over
6. Tingling or numbness in your feet
7. Sense of drowsiness, lethargy during the day not associated with missing meals or not sleeping
8. Eating starchy foods, even if they are healthy and unprocessed (like rice, corn, beans, whole wheat or oats), causes you to gain weight or prevents you from losing weight (No [0] or Yes [8])
9. Sores heal slowly (No [0] or Yes [8])
10. Loss of hair on your legs (No [0] or Yes [8])

Total points from PART IV, Section B:
PART V, Section A

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Feel jittery
2. First effort of the day causes pain, pressure, tightness or heaviness around the chest
3. Exhaustion with minor exertion
4. Heavy sweating (no exertion, no hot flashes)
5. Difficulty catching breath, especially during exercise
6. Heart pounding, sensation of heart beating too quickly, too slowly or irregularly
7. Swelling in feet, ankles, and/or legs comes and goes for no apparent reason

Total points from PART V, Section A:
PART V, Section B:

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Muscle pain at rest
2. Cramp-like pains in your ankles, calves or legs
3. Numbness, tingling and prickling sensation in hands and feet
4. Cold feet and/or toes appear blue
5. Brief moments of hearing loss
6. Nausea comes and goes quickly unrelated to eating
7. Feel worse standing: legs get heavy and fatigued
8. Leg discomfort or fatigue relived by elevating legs
9. Fingers and toes numb in cold weather even when protected
10. Notice changes in your ability to feel pain or discriminate sensations of hot or cold (No [0] or Yes [8])
11. Body hair (on arms, hands, fingers, legs and toes) is thinning or has disappeared (No [0] or Yes [8])
12. Do you notice a decline in your ability to make decision, concentrate, focus attention or follow directions? (No [0] or Yes [8])

Total points from Part V, Section B
PART VI, Section A:

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Family friends, work, hobbies or activities you hold dear are no longer of interest
2. Do you cry?
3. Does life look entirely hopeless?
4. Would you describe yourself as feeling miserable and sad, unhappy, or blue?
5. Do you find it hard to make the best of difficult situations?
6. Sleep problems -- too much or too little
7. Changes in your appetite and weight (No [0] or Yes [8])
8. Lately you've noticed an inability ti think clearly or concentrate (No [0] or Yes [8])
9. Difficulty making decisions and/or clarifying and achieving your goals (No [0] or Yes [8])

Total points from PART VI, Section A:
Part VI, Section B:

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Does worrying get you down?
2. Does every little thing get on your nerves and wear you out?
3. Would you consider yourself a nervous person?
4. Do you feel easily agitated?
5. Do you shake and tremble?
6. Are you keyed up and jittery?
7. Do you tremble or feel weak when someone shouts at you?
8. Do you become scared at sudden movements or noises at night?
9. Do you find yourself sighing a lot?
10. Are you awakened out of your sleep by frightening dreams?
11. Do frightening thoughts keep coming back in your mind?
12. Do you become suddenly scared for no good reason?
13. Do you break out in a cold sweat?
14. "Butterflies in your stomach", nausea and/or diarrhea

Total points from Part VI, Section B:
Part VI, Section C:

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Do you feel pent up and ready to explode?
2. Are you prone to noisy and emotional outbursts?
3. Do you do things on impulse?
4. Are you easily upset or irritated?
5. Do you go to pieces if you don't control yourself?
6. Do you little annoyance get on your nerves and make you angry?
7. Does it make you angry to have anyone tell you what to do?
8. Do you flare up in anger if you can't have what you want right away?

Total points from Part VI, Section C:
Part VII, All Sections:

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Eyes water or tear
2. Mucous discharge from the eyes
3. Ears ache, itch, feel congested or sore
4. Discharge from ears
5. Is your nose continually congested?
6. Are you prone to loud storing? (No [0] or Yes [8])
7. Is your nose continually congested?
8. Nosebleeds (No [0] or Yes [8])
9. Hoarse voice
10. Do you have to clear your throat?
11. Do you feel a choking lump in your throat?
12. Do you suffer from severe colds? (No [0] or Yes [8])
13. Do frequent colds keep you miserable all winter? (No [0] or Yes [8])
14. Flu symptoms last longer than 5 days (No [0] or Yes [8])
15. Do infections settle in your lungs? (No [0] or Yes [8])
16. Chest discomfort or pain
17. Do you experience sudden breathing difficulties?
18. Do you struggle with shortness of breath?
19. Difficulty exhaling (breathing out)
20. Breathlessness followed by coughing during exertion, no matter how slight
21. Inability to breathe comfortably while lying down
22. Do you cough up lots of phlegm?
23. Can you hear noisy rattling sounds when breathing in and out?
24. Are you troubled with coughing?
25. Do you wheeze?
26. Do you have severe soaking sweats at night?
27. Do your lips and/or nails have a blush hue?
28. Are you sleepy during the day?
29. Do you have difficulty concentrating?
30. Eyes, ears, nose, throat and lung symptoms seem associated with specific foods like dairy or wheat products (No [0] or Yes [8])
31. Eyes, ears, nose, throat and lung symptoms are associated with seasonal change (No [0] or Yes [8])

Total points from Part VII:
Part VIII

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Involuntary loss of urine when you cough, lift something or strain during an activity
2. Mild lower back ache or pain
3. Abdominal achiness or pain
4. Pain or burning when urinating
5. Rarely feel the urge to urinate
6. Feel the need to urinate less than every two hours day or night
7. Strong smelling urine
8. Back or leg pains are associated with dripping after urination
9. Sore or painful urination
10. Urine is rose color
11. Sudden urge to void causes involuntary loss of urine
12. Generalized sense of water retention throughout your body

Total points:
Part IX, Section A

Please fill out blanks below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Bones throughout your entire body ache, feel tender or sore
2. Localized bone pain
3. Hands, feet or throat get tight, spasm, or feel numb
4. Difficulty sitting straight
5. Upper back pain
6. Lower back pain
7. Pain when sitting down or walking
8. Find yourself limping or favoring one leg
9. Shins hurt during or after exercise

Total points from Part IX, Section A
Part IX, Section B:

Please fill in the blanks:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Are you stiff in the morning when you wake up?
2. Difficulty bending down and picking up clothing or anything from the floor
3. Joint swelling, pain or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet ankles, knees, ankles)
4. Joints hurt when moving or when carrying weight
5. A routine exercise program, like daily walking, causes your knees to swell or hurt
6. Difficulty opening jars that were previously easy to open
7. Discomfort, numbness, prickling or tingling sensation, or pain in neck, shoulder or arm
8. Intermittent pain or ache on one side of head spreading to cheek, temple, lower jaw, ear, neck and shoulder
9. Difficulty chewing food or opening mouth
10. Difficulty standing up from a sitting position
11. Shooting, aching, tingling pain down the back of leg
12. Is it difficulty to reach up and get a 5-pound object like a bag of flour from just above your head? (No [0] or Yes [8])
13. Injure, strain or sprain easily (No [0] or Yes [8])

Total points from Part IX, Section B:
Part IX, Section C:

Please fill in the blanks:*

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Muscles stiff, sore , tense and/or ache
2. Burning, throbbing shooting or stabbing muscle pain
3. Muscle cramps or spasms (involuntary, after exertion/exercise)
4. Is muscle pain or stiffness grater in the morning than other times of the day?
5. Specific points on body feel sore when pressed
6. Feel unrefreshed upon awakening
7. Headaches
8. Pain at the sides of your head or in your face especially when awakening
9. You jaw clicks or pops
10. Muscle twitch or tremor - eyelids, thumb, calf muscle
11. Irresistible urge to move legs
12. Legs more during sleep
13. Unpleasant crawling sensation inside calves when lying down
14. Hand and wrist numbness or pain (e.g. interferes with writing, buttoning or unbuttoning your clothes)
15. Feeling of "pins and needles" in your thumb and first three fingers
16. Pain in forearm and sometimes in shoulder

Total points from Part IX, Section C:
Part X, Section A:

Please fill out and add totals below:

	No/Rarely (0 points)	Occasionally (1 point)	Often (4 points)	Frequently (8 points)
1. Head feels heavy
2. Dizziness
3. Difficulty bending over, standing up from sitting, rolling over in bed and/or turning your head from side to side
4. Your hands tremble, ever so slightly for no apparent reason
5. When walking you feel like you're wearing heavy weights on your feet
6. Bump into things, trip, stumble and feel clumsy
7. Difficulty breathing
8. Difficulty swallowing
9. People tell you to speak up because they have trouble hearing you
10. Speaking and forming words does not feel automatic
11. Need 10-12 hours of sleep to feel rested
12. Lack strength (your grip is weak, holding your head or picking your arms up takes effort)
13. Hands get tired when you write and your handwriting is less legible and smaller than it sued to be
14. Muscles in arms and legs seem softer and smaller
15. Is your eyesight, sense of smell and taste or ability to hear not as sharp as it used to be?
16. Do you find yourself moving slower than you used to?

Total points from Part X, Section A:
Part X, Section B:

Please fill out and add totals below.

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
1. Difficulty absorbing new information
2. Tend to forget things
3. Trouble thinking or concerntrating
4. Easily distracted
5. Do you have a tendency to become frustrated quickly?
6. Inability to sit still for any length of time, even at mealtime
7. Finishing tasks is easier said than done
8. Do you have more trouble solving problems or managing your time than usual?
9. Low tolerance for stress and otherwise ordinary problems

Total points from Part X, Section B:
Part XI, MEN ONLY:

Please fill out and add totals below.

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
1. Sensation of not emptying your bladder completely
2. Need to urinate less than 2 hours after you have finished urinating
3. Find yourself needing to stop and start again several times while urinated
4. Find it difficult to postpone urination
5. Have a weak urinary stream
6. Need to push or strain to begin urination
7. Dripping after urination
8. Urge to urinate several times a night

Total points from MEN ONLY Section:
Part XII, WOMEN ONLY:

Section A (Menopausal women should skip to Sections E and F)

Do you persistently experience any of these symptoms within three days to two weeks prior to menstruation? [0 = NO] or [8 = YES]

	No [0]	Yes [8]
1. Anxious, irritable or restless
2. Numbness, tingling in hands and feet
3. Easy to anger, resentful
4. Aggressive or hostile toward family/friends
5. Abdominal bloating, feeling swollen (e.g., feet)
6. Temporary weight gain
7. Breast tenderness, swelling
8. Appearance of breast lumps
9. Discharge from nipples
10. Nausea and/or vomiting
11. Diarrhea or constipation
12. Aches and pains (back, joints, etc.)
13. Cravings for sweets
14. Increased appetite or binge eating
15. Headaches
16. Being easily overwhelmed, shaky or clumsy
17. Heart pounding
18. Dizziness or fainting
19. Confused and forgetful to the point that work suffers
20. Overwhelmed with the feelings of sadness and worthlessness
21. Difficulty sleeping or falling asleep
22. Engaging in self destructive behavior

Total points from PART XII, Section A:
Part XII, Section B:

Women Only.

Do you experience any of these symptoms during your period?:

	No [0]	Yes [8]
1. Cramping in lower abdomen or pelvic area
2. Pain is sharp and/or dull or intermittent
3. Bloating and sense of abdominal fullness
4. Diarrhea or constipation
5. Nausea and/or vomiting
6. Low back and/or legs ache
7. Headaches
8. Unusual fatigue (take naps) resulting in missed work
9. Painful and/or swollen breasts
10. Scanty blood flow

Total points from Part XII, Section B:
Part XII, Section C:

Women Only.

Please fill out and add totals below.

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
1. Painful or difficult sexual intercourse
2. Low abdominal, back and vaginal pain throughout the month
3. Pelvic pressure or pain while sitting down or standing up relieved by lying down
4. Vaginal bleeding other than during your period
5. Painful bowel movements
6. Difficulty (straining) urination
7. Abnormal vaginal discharge
8. Offensive vaginal discharge
9. Vaginal itching or burning with or without intercourse
10. Pain during periods is getting progressively worse (No [0] or Yes [8])
11. Profuse or prolonged menstrual bleeding (No [0] or Yes [8])
12. Unable to get pregnant (No [0] or Yes [8])

Total points from Part XII, Section C:
Part XII, Section D:

Women Only.

Please fill out and add totals below.

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
1. Absence of periods for six months or longer (No [0] or Yes [8])
2. Periods occur irregularly (e.g., e to 6 times a year) (No [0] or Yes [8])
3. Profuse heavy bleeding during periods
4. Menstrual blood contains clots and tissue
5. Bleeding between periods can occur anytime
6. Menstrual bleeding at cycles greater than every 35 days (No [0] or Yes [8])
7. Intense upper stomach pain, lasting several hours at the time you ovulate (approximately day 14 of your cycle)
8. Bleeding occurs at ovulation (approximately day 14 of your cycle)
9. Monthly abdominal pain without bleeding
10. Abundant cervical mucous
11. Acne and/or oily skin
12. Overwhelming urges for sexual intercourse
13. Aggresive feelings
14. Increased growth of dark facial and/or body hair (No [0] or Yes [8])
15. Poor sense of smell (No [0] or Yes [8])
16. Voice is becoming deeper (No [0] or Yes [8])
17. Breasts seem to be getting smaller (No [0] or Yes [8])
18. Receding hairline (No [0] or Yes [8])

Total points from Part XII, Section D:
Part XII, Section E:

Women Only.

Please fill out and add totals below.

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
1. Vaginal discharge
2. Vaginal secretions are watery and thin
3. Vaginal dryness
4. Sexual intercourse is uncomfortable
5. Interest in having sex is low
6. Engorged breasts
7. Breast tenderness, soreness
8. Difficulty with orgasm
9. Vaginal bleeding after sexual intercourse
10. Do you skip periods? (No [0] or Yes [8])
11. The length (number of days) of your period varies month to month, with the number of days of bleeding getting less (No [0] or Yes [8])

Total points from Part XII, Section E:
Part XII, Section F:

Women Only.

Please fill out and add totals below.

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
1. Sense of well-being fluctuates throughout the day for no apparent reason
2. Sudden hot flashes
3. Spontaneous sweating
4. Chills
5. Cold hands and feet
6. Heat beats rapidly or feels like it is fluttering
7. Numbness, tingling or prickling sensations
8. Dizziness
9. Mental fogginess, forgetful, distracted
10. Inability to concentrate
11. Depression, anxiety, nervousness and/or irritability
12. Difficulty sleeping
13. Consciousness of new feelings of anger and frustration
14. Skin, hair, vagina and/or eyes feel dry
15. Stopped menstruating around six months ago, yet still experience some vaginal bleeding (No [0] or Yes [8])

Total points from Part XII, Section F:
Body Check

Please identify areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color or texture (e.g., moles, rashes, etc.). Describe what you feel or observe in your own words.
Use reference image above.
4 DAY EATING HABITS
DAY TWO

MonthDayYear
Date
Time of Day / Description of Meal / Feeling After Meal
DAY TWO

MonthDayYear
Date
Time of Day / Description of Meal / Feeling After Meal
DAY THREE

MonthDayYear
Date
Time of Day / Description of Meal / Feeling After Meal
DAY FOUR

MonthDayYear
Date
Time of Day / Description of Meal / Feeling After Meal
© 2000 Lyra Heller, Michael Katke and Chris Katke. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law.
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Client Questionnaire

HEALTH HISTORY

Medical History

Health Habits

Exercise

Nutrition & Diet

Food Frequency

Eating Habits

Current Supplements

Health Appraisal Questionnaire

PART I: Section A

PART I: SECTION B

PART I: SECTION C

PART I: Section D

PART II

PART III: Section A

PART III: Section B

PART IV: Section A

PART IV: Section B

PART V, Section A

PART V, Section B:

PART VI, Section A:

Part VI, Section B:

Part VI, Section C:

Part VII, All Sections:

Part VIII

Part IX, Section A

Part IX, Section B:

Part IX, Section C:

Part X, Section A:

Part X, Section B:

Part XI, MEN ONLY:

Part XII, WOMEN ONLY:

Part XII, Section B:

Part XII, Section C:

Part XII, Section D:

Part XII, Section E:

Part XII, Section F:

Body Check

4 DAY EATING HABITS