Introducing Chantel Hilbert & Chelsea Wenger
About Us:
Chantel Hilbert, BSN RN and Chelsea Wenger, BSN RN have over 18 combined years of experience serving the Salem community as Registered Nurses in varying capacities, including: mental health, critical care, labor and delivery, surgical services, general medical services, chronic disease management, and home health. Additionally, Chantel and Chelsea are equipped with a unique knowledge set and heart for those considering or who have already had bariatric surgery and those struggling with autoimmunity, chronic pain, and food intolerances. Utilizing their health education and personal experience, coupled with their passion for holistic health, preventative care, and a desire to see their community thrive, Chantel and Chelsea have come together to provide various services including: Health consulting Educational classes In-person or remote appointments. Chantel and Chelsea look forward to meeting you and discovering how we can help you achieve the level of wellness you have been searching for.
HEALTH EVALUATION FORM
The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete. Once completed you will receive an email to set up an appointment. We look forward to assisting you!
Gender
Male
Female
Age
Full Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
How did you hear about this wellness form?
*
Chantel Hilbert, BSN, RN
Chelsea Wenger, BSN, RN
Salem Wellness Group
Elevate Your Life Project
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Height
feet and inches
Weight
pounds
What are you looking to improve?
What are the main reasons you are seeking wellness services?
*
Weight loss
Detox
Disease Prevention
Pre-conception & Pregnancy Care
Digestive Support
Cardiovascular Protection
Stress Management
Dietary Advice
Energy
Immune System
Sports Enhancement
Pain Management
Other
The following three questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health 1-10
*
How do you rate your current level of energy or vitality 1-10
*
How do you rate your current stress levels 1-10
*
How many hours sleep do you get a night?
*
Do you have trouble getting to sleep?
*
Please Select
No
Yes
Do you wake often, or get woken easily?
*
Please Select
Yes
No
Do you have to go to the bathroom during the night?
*
Please Select
Yes
No
Do you snore or have breathing problems during sleep?
*
Please Select
Yes
No
Not sure
Do you have allergies?
*
Please Select
Yes
No
Please list any allergies
*
Please list any prescribed or over-the-counter medications you are currently taking or use regularly (e.g. blood thinners, laxatives, pain relievers, antibiotics, medications to regulate your blood pressure or blood sugar, etc)
Please list any supplements you are currently taking
What are your main health concerns? Please describe.
Are there any of the following medical conditions in your family history that you are aware of? Please select all that apply.
Arthritis
Asthma
Autoimmune Disorders (e.g. lupus, rheumatoid arthritis)
Bowel Disorders
Cancer
Dementia / Alzeihmers
Depression
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Low Blood Pressure
Mental Illness
Muscular Dystrophy
Obesity
Osteoporosis
Osteoporosis
Skin Disorders
Strokes
Thyroid Over Active
Thyroid Under Active
Other
Other
List any issues you have with your digestion, including bathroom habits, tummy troubles, reactions to certain foods, etc.
Do you have regular mentrual cycles?
Yes
No
Please describe your menstrual cycle. Any concerns?
What method of birth control do you use?
Do you have regular aches and pains in your body? If yes, how often, where?
Have you ever been diagnosed with, or suspected that you have an autoimmune, thyroid, or otherwise chronic condition? If yes, which one?
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Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
Please list the types of exercise you do regularly
What physical activities do you enjoy?
examples: HIIT, yoga, martial arts, hiking, walking, crossfit, running, biking, etc.
Do you smoke cigarettes?
*
Please Select
Yes
No
How many per wk?
Do you use any of the following?
Recreational or Medical Cannabis
Opiods
Elicit drugs
Please list any food allergies / intolerances that you are aware of?
How many ounces of water do you have a day?
*
List other beverages consumed, and quantity per day
example: coffee, tea, energy drink, soda, milk, gatorade, kombucha, etc
Do you drink alcohol?
Yes
No
How many times per week?
*
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Frequency of exercise (days per week):
*
6 - 7
3 - 5
1 - 2
0
Vegetarian or vegan:
*
Please Select
Vegan
Vegetarian
Other
No
Planning to have a baby in the next 3-6 months:
*
Please Select
No
Yes
Pregnant or breastfeeding:
*
Please Select
No
Yes
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Do you diet often?:
*
Please Select
No
Yes
If yes, what have you tried or currently doing?
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
*
Are you unhappy with your weight?:
*
Please Select
No
Yes
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Would you like us to E-mail you a copy of your HAQ?
*
Please Select
Yes
No
Your Preferred E-mail Address
*
Additional info you might want to share
We are looking forward to meeting with you to review your results very soon!
Thank you for taking the time to complete this info before our appointment!
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