Medical Qigong Health Questionnaire
Please provide your health details to help me understand your needs.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Please complete this sentence - "Things have never been the same since...." Ex. Any major illness, surgery, trauma, childhood problems, etc.
*
Please list any chronic illnesses, surgeries, or hospitalizations.
How would you rate your current stress level?
1
2
3
4
5
How would you describe your sleep quality?
Excellent
Good
Average
Poor
Do you have trouble
Falling asleep
Staying asleep
How is your current pain level?
*
No pain
1
2
3
4
5
6
7
8
9
Worst
10
1 is No pain, 10 is Worst
Medical History
*
AIDS/HIV
Alcoholism/Substance Abuse
Allergies
Anxiety
Asthma
Cancer
Celiac Disease
Depression
Diabetes
Emphysema
Endocrine Disorders
Fibromyalgia
Gout
Heart Disease
Hepatitis A/B/C
Herpes
High Blood Pressure
Infectious Disease
Low Blood Pressure
Lyme Disease
Multiple Sclerosis
Obesity
Osteoarthritis
Osteoporosis
Pacemaker
Seizures
Stroke
Thyroid Disorder
Transfusions
Tuberculosis
Varicose Veins
None of the above
Other
Do you drink alcohol?
*
More than one drink per day
One drink per day
Rarely or none
Do you smoke tobacco products?
*
Please Select
Yes
No
If yes, how much?
Are you pregnant?
Please Select
Yes
No
Do you have an active cancer diagnosis?
*
Please Select
Yes
No
Do you believe in a higher power (ex. God, source, inner voice, etc.)?
*
Please Select
Yes
No
Please list and issues below that's not covered above
Submit
Should be Empty: