Client Questionnaire

Client Questionnaire

This questionnaire is for all new clients before attending your initial consultation. Thank you for taking the time to outline your health story in detail. It provides me with great insight into your current status & will become our measure of success, as we progress.
ZoomPhoneIn Person
Referred by a Friend / Family MemberReferred by a Health PractitionerReferred by a CoachQuantum Healing WebsiteGoogleInstagramFacebookOther
Please write name of referral below*
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Phone Number*
Mobile*

Area CodePhone Number
Date of Birth*

DayMonthYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation*
Include hours/wk
Weight*
Include Historic Weight & Gain/Loss Goal
Blood Pressure & Pulse*
If available
Priorities for Improvement*
Medical History*
Brief point form please
Family History*
Diagnosed conditions
Children*
Including age
Immune Challenges*
Asthma, Hayfever, Regular Cold/Flu, Covid Jabs, Skin Conditions
Allergies*
Intolerances, Sensitivities, Anaphylaxis
Skin*
Dermatitis, Eczema, Psoriasis, Shingles, Hives, Rosacea, Dandruff, Tinea
Nails*
Brittle, White Spots, Ridges, Soft, Chew
Stress*

1

2

3

4

5

1 is Low, 5 is High
Anxiety*

1

2

3

4

5

1 is Low, 5 is High
Stress Signs & Symptoms*
How does stress show up in your life?
Sleep*

1

2

3

4

5

1 is Worst, 5 is Best
Sleep Pattern*
Slow onset, Disturbance (Why), Apnea, Waking Unrefreshed
Energy*

1

2

3

4

5

1 is Low, 5 is High
Hormone Symptoms/Conditions*
Pain, Regularity, Heavy/Light, PMS, UTI, Urinary
Digestion Status*
Bloating, Reflux, Cramps, Constipation, Diarrhea, Bowel Motions/day
Have you had an COVID Vaccinations? If so, which ones & boosters? What were the injection dates?*
Please Upload Photo of Open Tongue*

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Optional: For online consults, please send photos of eyes to assess Iridology

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CLICK HERE to watch How to Upload Iris Photo Video
Diet*
Typical Breakfast*
Include variations & frequency per week
Typical Lunch*
Include variations & frequency per week
Typical Dinner*
Include variations & frequency per week
Popular Snacks*
Include variations & frequency per week
Coffee*
Type & how many per day
Alcohol*
Include variations & frequency per week
Smoking*
Number/day, How many years?
Exercise*
Type & frequency
Musculoskeletal*
Location, Frequency, Duration, Score ?/10, History, Type, Injury
Medication*
Include dosage and how long you have been medicated
Supplementation*
Pathology Test Results

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If you have any questions, please do not hesitate to contact me at support@kimballerobyzen.com

I am looking forward to achieving your health goals together.

Thank you for your time & expect to hear from me soon.

Kind regards,
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