New Client Health Assessment Form

New Client Health Assessment Form

Please provide your health information to help us understand your needs and offer the best care.
Date of Birth*

MonthDayYear
Date
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Emergency Contact Name*
Do you have any of the following chronic conditions?*

DiabetesHypertensionHeart DiseaseAsthmaArthritisNone of the aboveOther
Do you have any allergies?*

Medication AllergiesFood AllergiesEnvironmental AllergiesNoneOther
Please specify your allergies
List any current medications you are taking
How often do you exercise?*

DailySeveral times a weekOccasionallyRarelyNever
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*

SmokingAlcohol Consumption1-2 glasses per day3-4 glasses per dayRegular Exercise1-2 times per week3-4 times per weekHealthy Diet please describe in notes
Symptoms*

FeverCoughFatigueHeadacheShortness of BreathWaking up in the middle of the nightTrouble falling back to sleepUpset stomachDiarrheaConstipationCrampingGasOther
Do you or anyone in your family have a history of the following medical conditions?*

DiabetesHypertensionHeart DiseaseAsthmaNoneAge-related Macular DegenerationAlzheimer's DiseaseOsteoporosisCancerAuto-Immune disorders
Have you noticed any changes to your vision?

YesNo
Current Health Concerns
What is the current season where you live?

WinterSpringSummerFall
How much sun exposure do you get on a daily basis?

Less than 20 minsBetween 20 - 60 minsMore than an hourNone
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, perfumesAir fresheners, laundry detergent, dairy products, meats, cheesesHair care products, nail products, new and unwashed clothingWood 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 sleepIncreased EnergyImmune SupportFight Premature agingFill in nutritional gapsImproved digestionLong-term health goalsHelp with a high-stress lifestyleImproved skin toneJoint supportWeight LossBuild muscle and get stronger
Do any of the following apply to you?

Chronic Pain (always hurting)Acute PainDry HairThinning Hair or Hair lossAcneSkin issues, rashes, eczema, psoriasisBrittle nailsI'm underweightI'm overweight
Are you taking a weekly dose of 50,000 IU of vitamin D?

YesNo
Women: Do you suffer from premenopausal symptoms such as night sweats, heavy periods, hot flashes, mood swings, insomnia, fatigue or weight gain?

yesNoPlease describe in Notes
Men: Do you suffer from frequent urinations at night, erectile dysfunction, low testosterone, or enlarged prostate?

YesNoPlease describe in Notes
Women: Are you on Hormone Replacement Therapy or an oral contraceptive?

YesNoPlease describe if Yes in Notes on which one
How many 4 oz (size of your palm) servings of fruit do you eat daily?

None1-23-4
How many 4 oz (size of palm) servings of vegetables do you eat daily? (not counting potatoes)

None1-23-4
Do you regularly eat processed meats? Bacon, Bologna, lunchmeat, hot dogs

No, I never eat processed meat1-22-33-4
How often do you eat cold water, fatty fish? Cod, Halibut, Sardines, Tuna, Mackerel, Flounder or Herring

1-2 times per week2-3 times per week3-4 times per week>4 times per weekNone
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 week3-4 times per week4-5 times per week> 5 times per weekNone
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 day3-4 times per day5-6 times per day>6 times per dayNone
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 day3-4 times per day5-6 times per day> 6 times per dayNone
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 EneregyOnly average. Some days I lack energy.Poor. Continual physical exhaustion daily
How would you describe your stress level?

Low. Very seldom. 1-3Moderate. Sometimes 4-6Frequent. High 7-9Very High Scale of 10
What is your height?
What is your weight?
What description best describes your joint pain?

No Joint painPeriodic - sometimesContinual - all the time
What best describes your bone health?

Optimal. No ConcernsSome Concerns about calcium intakeVery Concerned. Diagnosed with osteoporosis or osteopenia
Do you commonly have any digestive problems such as burping, bloating, gas, bowel irregularity

NoLowModerateHigh
Do you commonly have any of the following:

DiarrheaConstipationHard StoolsOnly have BM's several times per week
Should be Empty: