HEALTH EVALUATION FORM
The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete
Full Name
First Name
Last Name
Gender
Male
Female
E-mail
Phone Number
-
Area Code
Phone Number
Back
Begin
GENERAL INFORMATION
Height if known
Weight if known
What are the main reasons you are seeking assistance?
*
Pain management
Headaches
Chronic illness
Migraines
Digestive issues
Weight issues
Stress Management
Anxiety
Fatigue
Immune System
Brain fog
Spiritual development
The following three questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health
*
How do you rate your current level of energy or vitality
*
How do you rate your current stress levels
*
How many hours sleep do you get a night?
*
Do you have trouble getting to sleep?
*
No
Yes
Do you wake often, or get woken easily?
*
Yes
No
Please list any known allergies
*
Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives, and natural remedies)
Please list any supplements you are currently taking
Do you have a main health complaint or challenge? Please describe.
Are there any of the following medical conditions in your family history that you are aware of? Please tick 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
Additional info you might want to share
Next: Diet and lifestyle . .
Back
Next
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
Do you take recreational drugs?
Yes
No
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?
*
Do you drink alcohol?
Yes
No
How many per week?
*
Back
Next
Patient health history
Frequency of exercise (days per week):
*
6 - 7
3 - 5
1 - 2
0
Vegetarian or vegan:
*
No
Yes
Age >50 years:
*
No
Yes
Pregnant or breastfeeding:
*
No
Yes
Back
Next
What types of food do you eat most often
*
Fast food
Frozen food
Restaurant
Homemade whole foods
Do you diet often?:
*
No
Yes
Are you unhappy with your weight?:
*
No
Yes
Back
Next
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
*
Your Preferred E-mail Address
*
Finish
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