Jac Health and Wellness Health History Questionnaire

Health History Questionnaire

Dr. Oskar Jacunski, Board Certified Doctor of Integrative Medicine, Board Certified Doctor of Humanitarian Services, Registered Nurse, Board Certified Health Coach, Reiki Master
Date

MonthDayYear
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. This is considered confidential. If you have anything you wish to bring to our attention, which is not asked on this form, please note it in the Comments section.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex at Birth*
Relationship Status
Address
City
State
Zip
Preferred Phone*
Email*
example@example.com
Emergency Contact (Name, Phone #, Relationship)*
Religious Preference*
Occupation*
HISTORY
Are you currently working?
Employed
Part-Time
Unemployed
Retired
Student
Any physical restrictions?
Any recent hospitalizations or surgeries?
Have you ever had any recent shots/vaccinations?
Are you currently taking antibiotics?
What are your hobbies?
Please check if any of these are part of your Personal health history

Abdominal painDecreased range of motionNervous tensionBroken bonesHeart attack
Please check if any of these are part of your Personal health history

DepressionNeuropathyBreast augmentationFrequent headachesBursitis/gout
Please check if any of these are part of your Personal health history

DiabetesPacemakers/DefibrillatorDigestive disordersSeizuresHIV/AIDS
Please check if any of these are part of your Personal health history

Disc ProblemsStrokeArthritisFibromyalgiaUlcerative Colitis
Please check if any of these are part of your Personal health history

StrokeArthritisFibromyalgiaThyroid problemsCandida overgrowth
Please check if any of these are part of your Personal health history

HypertensionChest painVaricose veinsCurrently pregnantAnxiety
Please check if any of these are part of your Personal health history

Breathing problemsConstipation/diarrheaSleep problemsExcess mucusSkin problems (itching/rashes)
Accident
Addictions (alcohol, tobacco, caffeine)
Allergies to oils/perfumes
Surgery
Cancer
Pain (specify)
Other (specify)
Do you take any medications?*
List all medications you are currently taking
Medications (continued)
List all medications you are currently taking
Supplements*
List all supplements you are currently taking
Supplements (continued)
List all supplements you are currently taking
Name of illicit/recreational drugs used in the last month
Number of extreme toxic exposures this year (radiation, insecticide, chemicals) to the best of your knowledge
Diet and Lifestyle
How many meals do you eat per day?
How many snacks?
What foods do you usually eat per meal? (Typically)
Breakfast
Lunch
Dinner
What is the source of your drinking water?
Number of glasses of water you drink per day
Do you consume fruits and vegetables? How often?
Do you consume dairy or meat? How often?
Do you consume wheat or gluten? How often?
Are the products you purchase organic or kosher?
Do you experience any digestive issues?
Do you smoke or vape? If yes, how many packs/carts per day?
Yes
No
Street drug use (specify)
Number of alcoholic drinks a week
Number of sugar type products daily including soft drinks, ice cream, cookies, doughnuts, etc.
Do you have any environmental or food allergies?
Number of cups of coffee per day
Other caffeine products (daily)
Any other relevant diet related information
Exercise (how often/duration)
Lifestyle: Active (daily physical activities), Average (physical activities most of the week), Inactive (physical activities less than three days of the week)
Stress
Unresolved mental stress?
Is your occupation stressful? Explain.
Are there any stressful relationships (co workers/friends/family)?
Please answer-using scale of 0-10
Interpersonal stress
Family Stress
Stress at work/school
Stress from sickness
Financial stress
Stress from desire for things to be different
How much Personal Stress do you have in your life? (Scale 0 10)
Females only (next two questions)
Birth control use?

Yes
No
Type and length of birth control use
Self-awareness
Do you practice any form of relaxation, meditation, prayer?
Yes (specify)
No (why not?)
Have you noticed any connections between your perception of stress and your physical being?
If you decided to change your diet/lifestyle in order to improve your life, is there someone close to you that would support your decision?

YesNo
Do you have a support person? If so, who?
Is there anyone in your life that would make it difficult for you to follow through on such a change?
What is your biggest fear or concern about your health?
How long have you had this fear?
Do you feel there is an emotional connection with your current physical condition?
What do you think your body needs in order to heal?
Are you willing to change and take control of your health and life situations?

YesNo
Do you believe in God or some infinite source of power?

YesNo
What is your life mantra (a belief or phrase you live by)?
What illness/issues would you like support with during the upcoming visit?
What major physical or emotional traumas have you experienced in your life?
List three aspects in your life that you would like to improve or change.
Comments
Consent for Wellness Consultation

I believe the information I have been provided is accurate. I agree to participate in the wellness consulting services provided by: Dr. Oskar Jacunski. I understand that Dr. Oskar Jacunski does not function as a physician, diagnose or treat disease, nor do his services replace the necessary services provided by a licensed physician.
Client Signature*

Clear
Date*

MonthDayYear
Date
Print name (first, last)*

My Products

In Person Health and Wellness Consultation

$99.00

Virtual Health and Wellness Consultation

$69.00

Total

$0.00

Payment Methods

Credit Card

Cash App Pay

Should be Empty:

Health History Questionnaire

HISTORY

Payment Methods