Health Questionnaire
Screening questionnaire for Katrina Ellis
Name
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Email
example@example.com
Weight
*
Please enter your current weight
Height
*
Please enter your height
Blood Type
Please enter your blood type if known
Occupation
Please enter your current Occupation
How did you hear about Katrina?
Please enter how you heard about Katrina
Are you coming in for in-person or telehealth?
*
Yes or No
What outcome or result do you wish to fulfil from seeing Katrina?
*
Please enter what you want to accomplish
Are you seeing any other practitioners?
Please list your current practitioners
Do you have an online practitioner site or access to on? (eg Vital.ly)
*
Yes or No
Disclaimer: We require your consent to use information gathered in questionnaire forms and during pre-post interview settings. It is imperative that you understand and acknowledge that a consent is required for any services rendered. In signing this you acknowledge that any tests or services performed in relation to your consultation is not intended to diagnose any disease but is simply an analysis tool for information. Any advice given during a consultation is to improve lifestyle only and is not intended as a cure or replacement for medical advice.
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Please enter today's date
Please list the main complaints or health symptoms for which you require treatment:
*
How long has this been occuring for?
*
Do you have a great deal of stress in your life?
Please rate 1-10
What is the prime cause of your stress?
E.g Work, Family etc
Are you on any current medications?
Please list your medications
Are you currently on any supplements/Herbs/Natural products
Please list all of your supplements
Have you had any surgeries
Please list the operation and the year
Are you currently undergoing treatment, if so please explain
Have you recently been immunized, if so please list
Within 5 years
Is there any emotional or physical condition/health imbalances that run in your family?
Please list
Do you Smoke or Vape? Now or recently
Yes
No
Typical daily diet
Please enter what you generally eat throughout the day - Breakfast, Lunch, dinner and snacks
How much water do you drink?
Please enter how many glasses of water you drink
What type of water do you drink?
Please enter if you drink tap, filtered or alkaline water
Do you regularly excerise?
What type of exercise and how often
Have you been exposed to harmful chemicals?
Please enter what chemicals you have been exposed to
Do you have any amalgams or dental work?
E.g. implants, bridges etc
How much sleep do you get?
Please enter your sleep pattern
Is your sleep broken?
i.e. waking, difficulty falling asleep, please explain
Are you motivated and ready to make lifestyle/dietary changes?
*
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