The Donatelli Wellness Center - Health Questionnaire

The Donatelli Wellness Center - Health Questionnaire

Welcome! After you complete this form, we will contact you within 24 hours for YOUR FREE PHONE CONSULTATION.
Date

Month Day Year
Date
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
Age
Gender

Male Female
We do periodic follow ups with you. Please select the ways you would like for us to contact you. Select all that apply.

Email Cell Phone Text
How did you hear about us? Google search, referral, If from a friend, doctor, coach, trainer, etc., please list so we can thank them.
We offer on-line services for pain consultation, weight loss coaching and in home personal training. (Select all that apply.)

I would prefer to come into your office for my therapy sessions. Yes, I would like to do my therapy on-line, in the comfort of my home. I have experience using Face Time or Zoom
What are your main concerns? Injuries, chronic pain, etc.
What are these things preventing you from doing or achieving?
Have you tried any other treatments? Please list.
How long have you been experiencing pain/limitations from your injury or condition?
How would you describe yourself?

Pro or semi-pro athlete Serious recreational athlete Youth athlete in school sports Moderately active Couch potato
Do you participate in any sports or activities? Please list the position you play if you play any team sports.
Is using a natural approach to wellness important to you?
How soon would you want to start a program that can help you achieve your health goals?

I want to start now! Within a few weeks. Within 6 months.
Occupation
Height
Current Weight
Weight 1 year ago
Ideal Weight
Mother's age and health status.
Father's age and health status.
Any serious illnesses/hospitalizations/surgeries/limitations? (Please list the dates or your age the time the event took place):
What natural or alternative treatments have you tried? Please select all that apply.

Surgery Physical Therapy Chiropractic Rolfing Massage Reiki, or other Energy Work Acupuncture Cranial Sacral Therapy Hypnosis Meditation Egoscue Method Alexander Technique Nutritionist/Health Coach
What supplements/vitamins do you currently take?
Any known allergies/sensitivities? Are you taking medications for them?
Digestion: (Check if You Experiencing Any On A Regular Basis)

Irritable Bowel Syndrom (IBS) GERD, Gastro Esophageal Reflux Disease Burping, Gas, Bloating Heartburn or Sour Stomach Constipation Diarreah
Frequency of bowel movements?

1 time per day 2-3 times per day A few times per week. Once a week or less.
Are you have or are you being treated for any of the following conditions? (Please check all that apply)

HIV, AIDS Staff Infection, MRSA Hepatitis B Cold, Flu Herpes, Shingles Tuberculosis, TB COVID-19
Do you suffer from any of the following conditions?

Heart Disease Cancer Diabetes Parkinson's MS Scoliosis
What medications do you currently take?
When Is the last time you were on an antibiotic? Name of antibiotic?
Where you ever on antibiotics for an extended period of time (3 months or more)? For what condition? Name of antibiotic?
Are you on hormone replacement therapy (HRT)?
Hormone Replacement Therapy?
What time do you normally go to sleep? What time do you normally wake up?
Do you wake up in the middle of the night? How often? Please explain why.
Do you feel rested when you wake up?

Yes, I almost always feel great when I wake up. Sometimes I feel rested when I wake up. I feel pretty good once I have my coffee. I am usually still very tired when I wake up.
Would you like to sleep better?

Yes, I would like to sleep better. I sleep good so it is not really a concern of mine.
For Woman Only

Next 7 questions:
Are Your periods regular?
Painful or Symptomatic?
Have you had children?
Reaching or approaching menopause?
Any abdominal surgeries, C-Section, Lipo. If Yes, any ongoing side effects from the surgery?
Dietary Information

Please fill out this section even if you are coming in for pain relief because your diet can affect inflammation, your pain level and how quickly you will heal.
What do you like to eat for breakfast?
What do you like to eat for lunch?
What do you like to eat for dinner?
Snacks
How much water & other beverages do you drink throughout the week.
Do you crave sugar, coffee, chocolate, cigarettes or other?
Are you currently on diet or a nutrition program?
Have you ever kept a food journal or diary?
What percent of your food is home cooked?
Where do you get the rest from?
Do You own any of the following?

Blender Juicer Vitamix, Nutribullet, Nija Rice Cooker Crock Pot Instantpot
What are 1-3 things that you know you can do and should do to improve your health?
Is there anything else you would like to share?
Congratulations!

We will now contact you within 24 hours for your FREE PHONE CONSULTATION to discuss if you qualify and how our program can help you. Thank You!
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The Donatelli Wellness Center - Health Questionnaire

For Woman Only

Dietary Information

Congratulations!