Client Goals, Health & History Questionnaire
Strength Smith Training Systems LLC
** Please allot approximately 1 hour to fill this form completely **
This form contains sections to submit files *Copies of Lab Work & 1 Week Food Journal* for your convenience, it is recommended to have these files prepared ahead of time before you begin to fill in this form.
Client Goals
From 1-5 (with 1 being the top priority), please list your primary health goals.
Why have you chosen this order?
What will you gain from accomplishing these goals?
What is the time frame you want to accomplish these goals by?
What is the reality if these goals are not accomplished within this timeframe?
Please explain how you are feeling as you begin this process toward your goals.
General & Contact Information
Name
First Name
Last Name
Age
Date of Birth
Date of Last Physical Exam
Best Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Biomedical Section
Personal Health History
Any Medical Issues That Doctors Have Diagnosed?
Surgeries (Include Year, Reason, Hospital)
Medications & Supplements (Include Name, Dose, Frequency, Reason, Years))
Allergies to Medications (Name, Reaction)
Allergies to Food (Name, Reaction)
Allergies to Environment (Name, Reaction)
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Health Habits & Personal Safety
Exercise
Sedentary (None)
Mild Exercise (Climb Stairs, Walk 3 Blocks)
Occasional Vigorous Exercise (Work or Recreation, less than 4x/week for 30 min)
Regular Vigorous Exercise (Work or Recreation 4x/week for 30 min)
Do You Follow A Specific Diet or Have Diet Restrictions? (Please Describe)
Caffeine Intake
None
Low
Medium
High
Alcohol Intake
None
1-2 per month
1-2 per week
1-2 per day
More than 2 drinks per day
Do You Use Tobacco?
Yes
No
Do You Use Any Recreational Drugs?
Yes
No
Are You Sexually Active?
Yes
No
Are you trying for pregnancy?
Yes
No
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Family Health History
Grandparents (Age, Significant Health Problems)
Father, Mother, Sibling (Age, Significant Health Problems)
Children (Age, Significant Health Problems)
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Pain
Are You Experiencing Any Pain?
Yes
No
If Yes, Please Describe & Rate Pain 0-10 (0=No Pain, 10=Worst Pain Imaginable)
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Mental Health
Is Stress An Issue For You?
Yes
No
Do You Feel Depressed?
Yes
No
Do You Panic When Stressed?
Yes
No
Do You Have Problems With Eating Or Your Appetite?
Yes
No
Do You Cry Frequently?
Yes
No
Do You Have Trouble Sleeping?
Yes
No
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Additional Problem Areas
Please Select Any Additional Areas That May Be Creating Issues For You
Skin
Head/Neck
Ears
Nose
Throat
Lungs
Chest/Heart
Back
Intestinal
Bladder
Bowel
Circulation
Weight
Energy Level
Ability To Sleep
Other Pains/Discomfort
Labs
If you would like to discuss lab work- please email it to dr.matt@strengthsts.com
Holistic Health Questions
Temperature-How warm/cold you feel (not degrees) but relative to other people. Check all that apply.
Cold hands or feet
Chills
Cold "In Your Bones"
Areas of numbness
Thirst with no desire to drink
Absence of thirst
Excessive thirst
Thirst for Cold Drinks
Thirst for cold drinks
Night sweats
Unusual sweating
Hot hands, feet, chest
Hot flashes
Hot in the afternoon
Hot at night
Moisture-Your overall body moisture (hair, skin, mouth, bowels etc). Check all that apply.
Dry skin/hair/nails
Dry Eyes
Dry nose/nosebleeds
Dry lips
Dry throat
Dry mouth
Edema/Swelling
Rashes
Itching
Oily skin/hair
Pimples
Weight gain
Weight loss
Digestion. Check all that apply.
Two or less Bowel Movements per day
Three or more bowel movements per day
Stool keeps shape
Stool does not keep shape
Alternating diarrhea/constipation
Indigestion
Gas/Bloating
Belching
Poor Appetite
IBS
Nausea/Vomiting
Bad Breath
Heartburn
Excessive Hunger
Dry Stools
Difficulty passing stool
Tired after bowel movement
Foul smelling stools
Energy. Check all that apply.
Hard to get out of bed in the morning
Energy drops suddenly mid-day
Energy drops after eating
Fatigue
Dependence on caffeine for energy
Wired/feeling ungrounded
Body/Limbs feel heavy
Body/Limbs feel weak
Shortness of. breath
Heart palpitations
High Blood Pressure
Low Blood Pressure
Bleed/Bruise easily
Hard to concentrate
Poor memory
Dizziness/lightheaded
Headaches 1-2 per week
More than 2 headaches per week
Sleep. Check all that apply.
Sleep 1-4 Hours per night
Sleep 4-6 Hours per night
Sleep 7-9 Hours per night
Sleep more than 9 hours per night
Difficulty falling asleep
Waking to urinate between 1-3am
Waking to urinate between 3-5am
Nightmares or disturbed dreams
Restless sleep
Not feeling rested when waking
Emotions. Check all that apply.
Anger
Irritability
Anxiety
Worry
Obsessive thinking
Sadness
Grief
Depression
Joy
Fear
Timid/Shy
Indecision
Flavors & Cravings. Check all that apply.
Sweet (Like Sugar or Starchy foods)
Sour (Like Lemon/Lime)
Spicy (Like Hot Sauce)
Salty
Bitter (Like Coffee or Chocolate)
Eyes, Ears, Nose, Throat. Check all that apply.
Poor Vision
Night blindness
Red eyes
Itchy eyes
Spots in front of eyes
SInus congestion
Clear phlegm
Yellow Phlegm
Green Phlegm
Poor Hearing
High pitched ringing in the ears
Low pitched ringing in the ears
Excessive earwax
Itchy ear canal
Sore throat
Dental problems
Mouth sores
Cough
Urinary. Check all that apply.
Decrease in flow/dribbling
Fluid output is equal to input
Fluid output is more than input
Fluid output is less than input
Difficulty starting/stopping urination
Incontinence
Kidney Stones
Urgent Urination
Frequent Urination
Pain/Burning sensation when urinating
Cloudy Urine
Blood in urine
Other. Check all that apply.
Increase in sex drive
Decrease in sex drive
Premature ejaculation
Infertility
Discharge
Prostate disease
Genital pain
Fibroids/cysts
Hernia
Hemorrhoids
Additional Comments- Is there anything else pertinent that you would like to share?
Food Journal
Please Upload A Typical 1 Week Food Journal (Equivalent to 7 Days of what you normally eat for Breakfast, Lunch, Dinner, Snacks, Desserts & Beverages)
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