Input Questionnaire

The Bodhi Workshop
/ Client Input Questionnaire
Welcome!

In preparation for your initial appointment, please complete this form to the best of your ability so that I have an understanding of your health and lifestyle background - and goals. You can complete it electronically and or print out and send a scan / photos of your completed hard copy by email.

Thank you - I am looking forward to getting started and working with you towards your health and wellness goals.

Sarah
Firstly, please complete some basic information about you:
Name

First NameLast Name
Your email
example@example.com
Gender
Height (please specify units)
Weight (please specify units)
Occupation
Upload a current photo of yourself for your file (optional)

Cancelof
Now some questions about your overall health and lifestyle.

Please rate your satisfaction with each area of your life in the first column below, and note any change in these feeling over the past few months in the second column.

Rows	Currently	Has it changed in the past few months?
Diet
Exercise
Sleep
Relationships
Mental health
Physical health

Daily routine

I'd like to know a little more about your daily diet and lifestyle patterns. Please note your 'typical' waking, meal, snack, exercise and bed times by marking them in the table below:

Rows	AM	PM
1
2
3
4
5
6
7
8
9
10
11
12

I'm a confirmed creature of habit - pretty much follow the above routine every dayI do like to stick to a schedule, but enjoy a change once in a whiletend to go with the flow - eating and sleeping often have to fit in around life
Please tell me a little more about your diet.
Do you, or have you in the past followed any particular 'diet' or dietary guidelines?

In the past ....

Vegetarian Vegan Paleo Ketogenic Mediterranean Gluten-free Low carb Low fat Low salt DASH Elimination diet Time restricted eating / fasting Other (Please specify )
Currently ....

Vegetarian Vegan Paleo Ketogenic Mediterranean Gluten-free Low carb Low fat Low salt DASH Elimination diet Time restricted eating / fasting Other Type a label (Please specify )

)
Mostly planned - I am generally following a diet and monitor my nutritional intake (calories or nutrients)Mostly Intuitive - I listen to my body and eat what feels right in the momentSomewhere in between - sometimes planned, sometimes go with the flow
Ravenous - always have a good appetite and I get cranky if I miss a mealSteady - I can miss a meal but I prefer not too.Irregular - sometimes I'm not hungry all day, the other times I can't stop myself eating everythingIt varies more with my emotional state than physical state (stress or emotional eating)
Strong - I can eat just about anything and feel fine.Variable - Sometimes its fine the other times I'll get extremely bloatedSlow - I often feel tired after eating a meal and it takes me a while to digest food
Tendency towards constipation, sometimes movements are uncomfortablePretty regular, once a dayOn the looser side, regular movements
/ Lifestyle
High in the mornings, lower in the afternoon / eveningsHigher later in the dayMore or less constant throughout the day
Fall asleep easily, sleep soundly, but sometimes I don't sleep for many hoursIrregular - some nights are good, some quite brokenOften struggle to get to sleep, often have periods of wakingHeavy - but wake up still feeling tired

How often would you say you feel ....

Rows	Choose one option for each
Anxious or worried
Fatigued or exhausted
Irritable or angry
Sad or hopeless
Overburdened
Directionless
A sense of loss of control
Confused, unable to focus
Nervous or jittery
Unable to cope

Which of the following do you feel has the most impact on your overall sense of well-being?
Physical Health

1

2

3

4

5

1 is Most important, 5 is Least
Surroundings / environment

1

2

3

4

5

1 is Most important, 5 is Least
Current events / news

1

2

3

4

5

1 is Most important, 5 is Least
Friends & family

1

2

3

4

5

1 is Most important, 5 is Least
Work / career

1

2

3

4

5

1 is Most important, 5 is Least

Have you experienced any of the following health conditions, either in the past or currently?

Rows	Currently	In the past (please specify how long ago)	Please provide any more details you feel may be relevant (duration, on-going issues, medications)
Cardiovascular / Heart disease
High blood pressure
Hormonal imbalance
Immune disorder
Skin issues (psoriasis, rosacea, acne)
Cancer
Digestive disorder
Poor circulation
Insomnia
Substance addiction
Eating disorder
Anxiety or depression
Diabetes
Migraine
Chronic bacterial / fungal
infection
Other

How would you describe the amount of physical activity or exercise you do currently?

Rows	Currently	In the past
Extremely active - intense exercise 5-7 times per week
Very active - moderate-intense exercise at least 5 times per week
Active - moderate-intense - exercise 3-4 times per week
Moderately active - gentle exercise 3+ times per week or moderate to intense exercise 2+ times
Less active
Not active at all

Almost always following a set plan or weekly routineI do like to stick to a schedule, but enjoy mixing it up tooI tend to go with the flow - exercise fits in around life and how I feel
/ Your goals
What is your primary reason for seeking Nutritional therapy now?
In which area of your life would you most like to see change? Why?
Is there anything specifically that you feel may be stopping you from reaching your goals currently?
Is there anything else that you feel is relevant to your health, situation or goals and would like to tell me about before our consultation?
Please sign and hit the submit button below when you are ready - or send your completed & scanned forms to sarahsbodhiworkshop@gmail.com in advance of our consultation.

Thank you for taking the time to share this information with me. I look forward to working with you.
Please note your booked or preferred appointment times below and we will be in touch to confirm.
Appointment
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