Health Questionnaire

Health Questionnaire
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Process
Was the delivery long and/or difficult?
Comments
Was the birth Cesarean?
Comments
Breech / Cephalic?
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?
Any Childhood illnesses?
Did you have other traumas?
What? & When?
Did you have colic, reflux or difficulty feeding?
Loss of Whole Body Health (Age 5 - Present)
Did you / Do you smoke?
Do you / Do you drink Alcohol?
Did you / Do you take recreational Drugs?
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)
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?)
Have you been in any Accidents?
Specify?
Have you had surgery and organs removed or replaced?
Specify?
Sleeping habits?
Specify?
Sleeping Posture: (Trouble sleeping, sleep debt, wake up tired etc)
Did you / Do you have Occupational stress?
Specify?
Physical and/or Mental stress?
Specify?
Hobby / Sports injuries?
Specify?
Other Traumas or problems?
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:
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?
On a scale of 0-10, how much stress is in your life?
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)
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
Date

MonthDayYear
Date
Client Card

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

Posture
Ears Level:
Shoulders Level:
Pelvis Level:
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:
Foundation
Forward Bend Test:
Pelvis Height:
Power
Lumbar Curve:
Lat Bending:
Centre
Thoracic Curve:
Chest Breath:
Passion
Hump at Cervical/Thoracic Junction:
Neck Lat bending:
Pause
Forward Position of Head:
Neck Lat bending:
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