The Donatelli Wellness Center - Health Questionnaire

The Donatelli Wellness Center - Health Questionnaire

Welcome! This form allows us to serve you at the highest level. 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. *
Do You Use Social Media? (please select all that apply) *

No, I do not use social media platforms. Yes, Facebook Linkedin Instagram TikTok Snapchat
Would you be interested to document and feature your progress on the social media platform of your choice? *

No thank you, I prefer my privacy. Yes, I would love to use social media to showcase my before and after progress!
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, improve performance, etc. *
Why is fixing this or improving this important to you? *
Have you tried any other treatments? Please list.
How long have you been feeling pain or 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.
History: Any serious illnesses/hospitalizations/surgeries/limitations? (Please list the dates or your age the time the event took place):
What 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
History of any of the following conditions?

Have you ever worn braces? Scoliosis High or Low Blood Pressure Heart Condition Cancer Diabetes Parkinson's MS Arthritis Osteoperosis Respiratory Disorder Asthma Epilepsy Phlebitis Stress or Nervousness
Please elaborate on any yes answers to the history of conditions above.
What prescription 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.
How do you like to relax?
For Woman Only

Next 7 questions:
Are Your periods regular?
Painful or Symptomatic?
Are you Pregnant?

Yes No
Have you had children? Ages?
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?
Our 10-Session Program has over a 97% success rate with our clients, in part because we are always improving what we do and how we do it. If you choose to go forward with the program, would you be willing to share your feedback after you complete the program; Stating what you liked best and what can be made even better?

Yes, if this program works for me, I would be happy to give feedback. Yes, but my privacy is very important, only if my name is kept private. No, I prefer not to offer any feedback.
Is there anything else you would like to share?
Congratulations!

We are excited to talk with you and will contact you within 24 hours for your FREE PHONE CONSULTATION to discuss how we can provide you with solutions for chronic pain, better posture, improved healing, strength and performance.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

The Donatelli Wellness Center - Health Questionnaire

For Woman Only

Dietary Information

Congratulations!