Client Conditions and Symptoms Tracking Form
*Fields with an asterisk are required.
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
How did you hear about us?
*
If you were referred by someone please let us know so we can thank them.
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Client Narrative
Please SHARE your health and medical story that would help us help you. SHARE your challenges and goals you would like to accomplish on this journey to wellness.
How would you rate your overall health today?
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Very Poor
0
1
2
3
Excellent
4
0 is Very Poor, 4 is Excellent
If you could, what are three major health issues you would like to eliminate from your life?
*
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Complaints / Concerns
Before your first session in the Energy Enhancement System, please answer the following questions based on how you've been feeling for the last 30 days..
Physical: Please rate the severity of the following symptoms. Only click the ones that apply to you. Leave what doesn't apply to you blank.
Rows
Occasionally but not severe
Occasionally and severe
Frequently but not severe
Frequently and severe
Headache
Joint Pain
Muscle Pain
Back Pain
Stiffness or lack of mobility
Numbness or tingling
Rheumatoid arthritis
Osteoarthritis
Swelling
Nasal/sinus congestion
Cough
Skin Problems
Menstrual problems
Nausea, vomiting
Bowel disturbances (diarrhea, constipation, gas)
Urinary problems
Dizziness/vertigo
Infection
Vision issues
Hearing issues
Hair loss
Heart issues
Bladder/prostate issues
Lung/breathing issues
Allergies
Toxicity issues
Neurological issues
Calculation
Have you experienced any major physical trauma such as an accident? If so, how long ago? Please briefly describe it in the box below.
Optional: Additional issues, specifics, location ,or type of pain, etc.
Do you have reduced liver function?
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Yes
No
I don't know
Sleep: How would you rate each of the following? Only click the ones that apply to you. Leave what doesn't apply to you blank.
Rows
1 rarely
2
3
4 Daily
Trouble falling asleep
Trouble remaining asleep
Snoring
Sleepiness during the day
Waking in the morning still tired
Breathing issues during sleep
Frequent urination interrupts my sleep
Calculation
How many hours of sleep do you get a night?
Do you have any other sleep issues?
Mind: How would you rate each of the following? Leave blank if it doesn't apply to you.
Rows
1 Rarely
2
3
4 Daily
Long term memory loss
Short term memory loss
Confusion
Brain Fog
Learning disabilities
Loss for words
Speech issues
Calculation
Emotional: How would you rate each of the following? Only click the ones that apply to you. Leave what doesn't apply to you blank.
Rows
1 Rarely
2
3
4 Daily
Mood swings
Anxiety, fear or nervousness
Anger, irritability
Sadness, grief, depression
Sense of despair
Uncaring or disinterested
Calculation
We believe that unresolved or generational traumas, suppressed feelings, and unprocessed memories can lead to trapped emotions that physically manifest as symptoms. Do you think any of these underlying issues may be contributing to your current health concerns?
Yes
No
Energy: How would you rate each of the following? Only click the ones that apply to you. Leave what doesn't apply to you blank.
Rows
1 Rarely
2
3
4 Daily
Fatigue, sluggishness
Low daytime energy
Apathy, lethargy
Hyperactivity
Restlessness
Calculation
Please describe any other symptoms you are experiencing today.
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Nutrition/Hydration
Click all that apply to your current lifestyle and eating habits:
Negative relationship with food
Erratic eating patterns
Emotional eater
Eat too much/overeat
Don't eat enough
Eat fast food frequently
Eat out in restaurants frequently
Eat boxed or frozen meals often
Late night eating
Confused about food/nutrition
Dislike "healthy food"
Drink Sodas or diet drinks
Drink energy drinks
Consume artificial sweeteners
Cook with vegetable or seed oils
Sugar cravings
Rely on convenience items
Poor snack choices
Other
How would you best describe your diet? Click any that apply
Standard American Diet
Vegetarian
Vegan
Raw Vegan
Pescatarian
Flexitarian
Macrobiotic
Whole 30
Paleo
Organic
Gluten-Free
Keto
High Protein
Low Carb
Raw Foods
Other
How much water do you drink daily?
*
Where does your primary source of drink water come from?
Municipal
Well
Home Filtration System
Bottled
Other
Do you take any mineral supplementation?
Yes
No
How many alcoholic beverages do you consume in a week?
Rows
None
1-2
3-4
5-6
7 or more
Drinks
How many bowel movements do you have daily or weekly?
Are you currently nursing?
Yes
No
Please note any additional comments about your nutrition/eating habits:
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Physical Activity
Do you engage in moderate cardiovascular physical activity for a minumum duration of 20 minutes at least 3 days a week? For example: brisk walking, jogging, cardio exercise classes
Yes
No
Note any problems that limit your physical activity:
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Daily Stressors
How would you rate the stress level of each of the following items? Only click the ones that apply to you, leaving what doesn't apply to you blank.
Rows
1 Low
2
3
4 High
Work
Family
Relationships
Finances
Health
Education
Physical activity
Traumas
Calculation
Other
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Toxins
How much exposure have you had to the following? Only click the ones that apply to you. Leave blank if you are unaware of such exposure.
Rows
1 Low
2
3
4 High
Mold
Pesticides
Non Organic Fertilizers
Rodenticides
Herbicides
Fungicides
Paint and Paint Thinners
Wood Preservatives or Stains
Alloys
Dyes
Heavy Metals
Calculations
Please select any of the following conditions that you currently have or have had in the past.
Mold exposure in your home or work place
Water damage to your home or work place
Mercury Amalgam Fillings
Root canals
Any type of metal in your mouth or body
Tattoos with colored ink
Breast implants
IUD
Birth control
Use tobacco products
Vape
Worked in a mine
Worked around chemicals
Radiation exposure
Receive flu shots or vaccines
Other
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Air Quality
Do you currently use any of the following?
Burn candles
Scented laundry products
Scented body products
Air freshners
Perfumes or colognes
Exposed to second hand smoke
Home air filtration system
EMF Radiation protection devices
Please list any known environmental allergies?
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