Health Questionnaire

Health Questionnaire
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Birth Process
Was the delivery long and/or difficult?

YesNo
Comments
Was the birth Cesarean?

YesNo
Comments
Breech / Cephalic?

YesNo
Comments
Do you know of any stressful situation that may have been present for your mother or father or both?
Growth and Development
Did you roll out of bed or have any falls as a child?

YesNo
Any Childhood illnesses?

YesNo
Did you have other traumas?

YesNo
What? & When?
Did you have colic, reflux or difficulty feeding?

YesNo
Loss of Whole Body Health (Age 5 - Present)
Did you / Do you smoke?

NeverReformed SmokerDaily
Do you / Do you drink Alcohol?

NeverDid PreviouslyWeeklyDaily
Did you / Do you take recreational Drugs?

NeverDid PreviouslyWeeklyDaily
Have you recently taken recreational drugs? Please list them along with no of days / weeks since taking.
Do you take over the counter Drugs? (Prescriptive or Non-prescriptive)

NeverDid PreviouslyWeeklyDaily
If you have recently taken prescription drugs? Please list them along with no of days / weeks since taking.
Please include the drug function for eg, blood pressure, anti-arthritis etc.
Diet (do you eat healthy?)

Yes alwaysI try to eat HealthyNo
Have you been in any Accidents?

YesNo
Specify?
Have you had surgery and organs removed or replaced?

YesNo
Specify?
Sleeping habits?

YesNo
Specify?
Sleeping Posture: (Trouble sleeping, sleep debt, wake up tired etc)

NoSideStomachBack
Did you / Do you have Occupational stress?

YesNo
Specify?
Physical and/or Mental stress?

YesNo
Specify?
Hobby / Sports injuries?

YesNo
Specify?
Other Traumas or problems?

YesNo
Specify?
Present State of Health (Symptoms)
What is your body telling you right now? What symptoms are you experiencing? Please explainand describe what is happening in your body
When did this start?
What do you think the cause is?
Is this condition interfering with:

WorkSleepRoutineOther
If this were to go away tomorrow, what would be different about your life?
Are you living the life you would like to be?
On a scale of 0-10, how happy are you?

12345678910
On a scale of 0-10, how much stress is in your life?

12345678910
Are you ready to make changes to your life in order to heal, even if these changes are inconvenientto your lifestyle?
Any Other Symptoms you are experiencing (Please tick if applicable)

Neck PainStiff NeckHeadachesDizzinessFaintingEars RingBalance LossNumb ToesChest painFeverLoss of MemoryMigrainesThyroid IssuesSciaticaNumbness in FingersShoulder PainCold Feet/HandsLoss of smell/TasteCold/Flu AllergiesPain in Mid-spineCold SweatHearing problemsLights bother eyesMenstrual Pain StressNot SleepingFibromyalgiaNervousnessTension & IrritabilityFatigue/Sleeping problemsDepressionChronic FatiguePins & Needles / LegsShortness of BreathWeight ProblemsStomach/Digestive ProblemsConstipation/DiarrheaPins & Needles in ArmsDifficulty BreathingLower Back PainKnee Pain
What are you looking to get out of these sessions?
Have you had any trauma or abuse in your life?
Please let us know in a few sentences, how we can assist you and help you the most?
By signing this form, I agree and consent to the healing work. I understand that with any healing process and work on my body, my symptoms may worsen before they get better. I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate fix to my problem, and health is a process. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Client Card

	Name
1
2
3
4
5
6
7
8
9
10
11
12

Posture
Ears Level:

YesNo
Shoulders Level:

YesNo
Pelvis Level:

YesNo
Why are you here?:
If that were to improve how would your life be different?:
Physical Stressors:
Chemical Stressors:
Emotional Stressors:
Blockages
Base gateway
Heal to toe:

Less than 6 stepsMore than 6 steps
Foundation
Forward Bend Test:

EqualR HigherL Higher
Pelvis Height:

EqualR HigherL Higher
Power
Lumbar Curve:

BalancedMoreLess
Lat Bending:

EqualR MoreL More
Centre
Thoracic Curve:

BalancedMoreLess
Chest Breath:

NormalDecreased
Passion
Hump at Cervical/Thoracic Junction:

YesNo
Neck Lat bending:

EqualR MoreL More
Pause
Forward Position of Head:

YesNo
Neck Lat bending:

EqualR MoreL More
Should be Empty:

Health Questionnaire

Birth Process

Growth and Development

Loss of Whole Body Health (Age 5 - Present)

Client Card

Posture

Base gateway

Foundation

Power

Centre

Passion

Pause