Wellness Questionnaire

Wellness Questionnaire

Health History for 75-minute Consultation. NOTE: This is not for colon hydrotherapy.
Date of your Appointment

MonthDayYear
Full Name*

First NameLast Name
FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Referred By:
Date of Birth*

MonthDayYear
Age*
Height*
Weight*
Eye Color*
Blood Type
Family Physician
Physician's Phone Number

Area CodePhone Number
Vitals
pH Level

UrineSaliva
End - Vitals
Lifestyle/General Habits
How many bowel movements do you have, daily?*
How much water do you drink, daily?*
Do you smoke/vape, drink alcohol, or chew tobacco? Type which one or 'NONE'*
Do you use recreational drugs?*
Do you drink beverages or water with meals?*
What is your source of drinking water? (Examples: tap, distilled, bottled, alkaline)*
Do you use a microwave?*
Of what does your diet consist (What do you eat)?*
Note

Please Note: Some questions may be repeated, as they apply to different body systems.
Thyroid/Parathyroid (Glandular System)
RidgedBrittleWeakNone of the above
YesNo
YesNo
YesNo
HemorrhoidsProlapsed organsNo
StrongWeak
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNoFamily member
YesNo
End - Thyroid/Parathyroid (Glandular System)
Pancreas
YesNoOther
YesNo
YesNo
YesNo
YesNo
End - Pancreas
Adrenal Glands
Medulla (Adrenal)
YesNo
M.S.Parkinson'sPalsy
YesNo
YesNo
YesNo
HighLowAverage/Regular
What is your blood pressure? eg. 120/60
YesNo
Pre-DiabetesType IType IINo
YesNo
YesNo
Yes (falling asleep)Yes (staying asleep)No
Cortex (Adrenal)
YesNo
YesNoOther
Explain
End - Adrenal Glands
Females Only
YesNoI am menopausalI am not yet menstruating
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, for how long?
YesNo
Hot flashesHeart palpitationsPMS Mood swingsFoggy thinkingUrinary incontinenceVaginal drynessIncreased body/facial hairNight sweatsHistory of steroid usageMorning or Evening FatigueAllergiesFood CravingsSusceptible to Infections
Yes (bio-identical)Yes (regular/synthetic)No
End of 'Females-Only' Section
Males Only
YesNo
YesNo
What is your PSA count? Test Date:
YesNo
lowhighaverage
Night sweatsIrritableFoggy thinkingInfertilityFatigueDry SkinFeeling coldHeadachesHeart palpitationsFibromyalgiaStresslots of infectionsWeight gain (waist)Burned-out feelingErectile dysfunctionDecreased mental sharpness
End of 'Males-Only' Section
Gastro-Intestinal Tract
gastritisenteritisgastroparesisNo
whiteyellowgreen or brownno
YesNo
colitisdiverticulitisNo
YesNo
YesNo
YesNo
YesNo
Other gastrointestinal (GI) problems?
End - Gastro-Intestinal Tract
Liver/Gallbladder/Blood
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
NoHepatitis AHepatitis BHepatitis C
End - Liver/Gallbladder/Blood
Heart and Circulation
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesPacemakerStintsNo
End - Heart and Circulation
Skin
YesNo
YesNo
YesNo
DryOilyCombo
YesNo
End - Skin
Lymphatic System
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If so, where?
YesNo
YesNo
YesNo
When?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
At what age?
End - Lymphatic System
Kidneys and Bladder
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
End - Kidneys and Bladder
Lungs
BronchitisEmphysemaAsthmaC.O.P.D.
YesNo
How often?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
End - Lungs
Environmental Toxins
YesNo
YesNo
YesNo
YesNo
heavy metalschemicals (paints, batteries, industrial waste, etc.)pesticides
NoRadiationChemotherapy
End - Environmental Toxins
Chemical Medications

List all medications you are currently taking
Medication Names and Reason for taking:
List all supplements that you are currently taking
Allergies (Food/Seasonal/Environmental):
Past Surgeries - major and minor, and the year
Genetic/Family Medical History
Mother (How is/was her health?)
Father (How is/was his health?)
Maternal Grandfather (How is/was his health?)
Maternal Grandmother (How is/was her health?)
Paternal Grandfather (How is/was his health?)
Paternal Grandmother (How is/was her health?)
Siblings
You are nearing the end.
What are your major health concerns (please list anything that was not addressed in this questionnaire):*
Option to upload any document you feel is relevant.

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INFORMED CONSENT I am solely responsible for the decision to see Dr. Lesa Lawson, ND for naturopathic services and health coaching. I recognize that some recommendations may not prove to be successful. I understand that some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concern to Dr. Lawson. I also understand that any significant symptom should be reported to my medical doctor. I further understand that I should discuss the use of nutritional supplements with my medical doctor.*
Signature:
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Wellness Questionnaire

Vitals

Lifestyle/General Habits

Note

Thyroid/Parathyroid (Glandular System)

Pancreas

Adrenal Glands

Females Only

Males Only

Gastro-Intestinal Tract

Liver/Gallbladder/Blood

Heart and Circulation

Skin

Lymphatic System

Kidneys and Bladder

Lungs

Environmental Toxins

Chemical Medications

Genetic/Family Medical History

You are nearing the end.

Thank you!