Health Assessment Questionnaire
Katie Premac
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
What are your current health concerns?
List any current or previous medical diagnoses and approximate date of diagnosis
Please list any current medications/prescriptions and how long you have been taking them
Please list any current supplements and how long you have been taking them
How many hours of sleep do you get each night? Do you have trouble falling or staying asleep?If yes, please describe
Are you under or have you recently undergone chronic stress?
How much water do you drink each day?
Is your libido low or normal/high?
Please describe your caffeine consumption. How much, in what form and how often?
How much and how often do you drink alcohol?
Summarize your current diet
What do you do for exercise, and at what frequency and duration?
What are your main goals in working together?
The last questions are for women of reproductive age only, skip ahead to signature and date ifthis does not apply.
Are you currently taking or have you ever taken birth control? If yes, which form and how long have you/did you take it?
How long are your menstrual cycles?
Do you experience any PMS? If yes, what are your symptoms?
How many days do you bleed and how is the flow? Light, normal, heavy?
Are you currently breastfeeding?
Signature
Date
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Month
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Day
Year
Date
Submit
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