New Client Health Assessment Form
Please provide your health information to help us understand your needs and offer the best care.
Date of Birth
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Do you have any of the following chronic conditions?
*
Diabetes
Hypertension
Heart Disease
Asthma
Arthritis
None of the above
Other
Do you have any allergies?
*
Medication Allergies
Food Allergies
Environmental Allergies
None
Other
Please specify your allergies
List any current medications you are taking
How often do you exercise?
*
Daily
Several times a week
Occasionally
Rarely
Never
I consent to the collection and use of my health information for assessment and care purposes.
*
Lifestyle Habits - check if any of these apply to you
*
Smoking
Alcohol Consumption
1-2 glasses per day
3-4 glasses per day
Regular Exercise
1-2 times per week
3-4 times per week
Healthy Diet please describe in notes
Symptoms
*
Fever
Cough
Fatigue
Headache
Shortness of Breath
Waking up in the middle of the night
Trouble falling back to sleep
Upset stomach
Diarrhea
Constipation
Cramping
Gas
Other
Do you or anyone in your family have a history of the following medical conditions?
*
Diabetes
Hypertension
Heart Disease
Asthma
None
Age-related Macular Degeneration
Alzheimer's Disease
Osteoporosis
Cancer
Auto-Immune disorders
Have you noticed any changes to your vision?
Yes
No
Current Health Concerns
What is the current season where you live?
Winter
Spring
Summer
Fall
How much sun exposure do you get on a daily basis?
Less than 20 mins
Between 20 - 60 mins
More than an hour
None
Do you regularly use or come in contact with any of the following products in your home or place of business?
Plastic food container, cosmetics, perfumes
Air fresheners, laundry detergent, dairy products, meats, cheeses
Hair care products, nail products, new and unwashed clothing
Wood products, vehicle exhaust, tobacco smoke
Do any of the following statements apply to you?
I live in a major metropolitan city.
I use chemical insecticides or pesticides at my home or place of work.
I use chemical weed killers or pesticides at my home.
I use chemical weed killer or herbicides as part of my profession or live near an agricultural operation.
Are you looking for any of the following ?
Better quality sleep
Increased Energy
Immune Support
Fight Premature aging
Fill in nutritional gaps
Improved digestion
Long-term health goals
Help with a high-stress lifestyle
Improved skin tone
Joint support
Weight Loss
Build muscle and get stronger
Do any of the following apply to you?
Chronic Pain (always hurting)
Acute Pain
Dry Hair
Thinning Hair or Hair loss
Acne
Skin issues, rashes, eczema, psoriasis
Brittle nails
I'm underweight
I'm overweight
Are you taking a weekly dose of 50,000 IU of vitamin D?
Yes
No
Women: Do you suffer from premenopausal symptoms such as night sweats, heavy periods, hot flashes, mood swings, insomnia, fatigue or weight gain?
yes
No
Please describe in Notes
Men: Do you suffer from frequent urinations at night, erectile dysfunction, low testosterone, or enlarged prostate?
Yes
No
Please describe in Notes
Women: Are you on Hormone Replacement Therapy or an oral contraceptive?
Yes
No
Please describe if Yes in Notes on which one
How many 4 oz (size of your palm) servings of fruit do you eat daily?
None
1-2
3-4
How many 4 oz (size of palm) servings of vegetables do you eat daily? (not counting potatoes)
None
1-2
3-4
Do you regularly eat processed meats? Bacon, Bologna, lunchmeat, hot dogs
No, I never eat processed meat
1-2
2-3
3-4
How often do you eat cold water, fatty fish? Cod, Halibut, Sardines, Tuna, Mackerel, Flounder or Herring
1-2 times per week
2-3 times per week
3-4 times per week
>4 times per week
None
How would you describe your use or consumption of trans fat or seed oils when cooking or ingested? Vegetable oil, Canola oil, Corn oil, margarine, safflower oil or cottonseed oil
Never
< 5 times per week
> 5 times per week
Do you regularly consume protein shakes or protein bars?
1-2 times per week
3-4 times per week
4-5 times per week
> 5 times per week
None
How many times per day do you regularly consume sugar or other sweeteners such as sugar, agave, honey, coconut sugar, high fructose corn syrup, corn products or maple syrup?
1-2 times per day
3-4 times per day
5-6 times per day
>6 times per day
None
Additional Notes
How many servings of artificial sweeteners do you consume in a day? examples, sucralose, equal, splenda, aspartame, or other sugar alcohols
1-2 times per day
3-4 times per day
5-6 times per day
> 6 times per day
None
How would you describe your current sleep?
Great! I wake up fully rested.
Adequate. I sometimes hit the snooze or feel like I need a few more mins to feel rested.
Inadequate. I typically feel that I get less sleep than I need.
How would you describe your energy level?
I feel energetic. Very High Eneregy
Only average. Some days I lack energy.
Poor. Continual physical exhaustion daily
How would you describe your stress level?
Low. Very seldom. 1-3
Moderate. Sometimes 4-6
Frequent. High 7-9
Very High Scale of 10
What is your height?
What is your weight?
What description best describes your joint pain?
No Joint pain
Periodic - sometimes
Continual - all the time
What best describes your bone health?
Optimal. No Concerns
Some Concerns about calcium intake
Very Concerned. Diagnosed with osteoporosis or osteopenia
Do you commonly have any digestive problems such as burping, bloating, gas, bowel irregularity
No
Low
Moderate
High
Do you commonly have any of the following:
Diarrhea
Constipation
Hard Stools
Only have BM's several times per week
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