INTEGRATIVE HEALTH PATIENT SELF-ASSESSMENT

  • INTEGRATIVE HEALTH PROGRAM

    Ready to get started on your health and wellness journey? Fill out our patient self-assessment form!

  • PATIENT INFORMATION

  • Date of Birth*
     / /
  • Format: (000) 000-0000.

  • LIFESTYLE HISTORY

    PSYCHOSOCIAL
  • Marital Status*
  • Who is on your support team?*
  • Have you or your family experienced any major life changes?*
  • Have you experienced any major losses in life?*
  • Have you lived or traveled outside of the United States?*
  • Do you have any pets or farm animals?*
  • Do you drink alcohol?*
  • Do you use recreational drugs?*
  • Have you ever used tobacco?*
  • Are you currently employed?*
  • Do you work shifts?*

  • LIFESTYLE HISTORY

    Safety
  • Did you feel safe growing up?*
  • Was alcoholism or substance abuse present in your childhood or in current relationships?*
  • Have you been involved in abusive relationships?*
  • Do you feel safe, respected, and valued in your current relationship?*
  • Have you had any violent or otherwise traumatic life experiences, or have you witnessed violence or abuse?*
  • Have you ever had psychotherapy or counseling?*

  • MEDICAL HISTORY

  • Do your parents or siblings have (or had) any health issues?*

  • HEALTH AND WELLNESS

    Nutrition
  • Rows
  • As a child, did you eat a lot of sugar and/or candy?*
  • Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?*
  • Does skipping a meal greatly affect your symptoms?*
  • Do you have aversions to certain foods?*

  • HEALTH AND WELLNESS

    Physical Activity
  • Do you exercise?*
  • Are you active at work?*

  • ADDITIONAL SCREENING

  • Do you have constipation or diarrhea?*
  • Do you have intestinal gas?*
  • Do you have mercury amalgam fillings in your teeth?*
  • Do you have any artificial joints or implants?*
  • Do you feel worse certain times of the year?*
  • Are you affected by any odors?*
  • Are you exposed to secondhand smoke regularly?*
  • Have you been exposed to toxic metals at home or work?*

  • Congratulations, you are on the path to taking your first step towards health and wellness!

  • I have read and understand everything on this page. I acknowledge April Powell and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases April Powell, her lab partners, her independent representatives, associates, and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.

  • Date*
     / /
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