Senses of the Soul Health History Questionnaire

Senses of the Soul Health History Questionnaire
Each being is unique. No two persons are ever created exactly the same. Therefore, any attempt made to heal must be approached by treating each person individually according to their own particular patterns of disharmony.

About the Senses of the Soul Health History Questionnaire:

- You may want to grab a hot drink and allow at least 15 minutes to fill out this form, which was designed to create as complete a picture of you as possible.

- Your answers can always be adjusted later if you want to add something you forgot, or if you need to exit out before finishing you can submit your forms then return later to edit and finalize them.

- If you are not sure how to answer a question(s), or if you prefer not to answer a question, leave it blank for now. We can discuss it during your initial consultation.

- All information will remain confidential and would only be released with your written consent.

- Please note: all appointments will take place via Zoom and will no longer be in person

PLEASE NOTE: that some of the herbal medicines that I use for these consults contain alcohol (herbal tinctures). If you have an aversion to alcohol and will not take natural medicine in this form, then I cannot have you as a clinical client.

Blessings,
Samantha

Samantha Orthlieb, MH, RH
Registered Herbalist
Psychospiritual Nature Medicine Therapist
BioEnergetic Medicine
Contemporary Medicine Woman

Senses of the Soul Ltd
1 - 587 - 899 - SOUL (7685)
customerlove@sensesofthesoul.ca
www.sensesofthesoul.ca
Personal Information
Name

First NameLast Name
Email
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please tell us the preferred time zone for your Zoom consults
Phone Number

Area CodePhone Number
Age
Height
Weight
Occupation
Date of Birth

MonthDayYear
Date
Family Physician
Referred by
Main problem(s) you would like to be helped with:
How long ago did this problem begin (be as specific as possible):

To what extent does this interfere with your daily activities (work, sleep, etc)?

	1	2	3	4	5	6	7

1 is Not noticeable, 7 is Very noticeable

Have you been given a diagnosis for this problem - if so, what?
What kinds of treatments have you tried?
Are you presently being treated by a medical doctor/chiropractor?

YesNo
What are you being treated for:
Are you presently being treated by any alternative modes of healing

YesNo
What type of alternative modes are you trying:
Family History
Mother
Is your mother living?

YesNo
What is her current age or age at death
What is/was her general health?
What was the cause of death?
Father
Is your father living?

YesNo
What is his current age or age at death
What is/was his general health?
What was the cause of death?
General Family History

Please select the conditions present in your family

	Mother	Father	Grandmother	Grandfather	Sibling
Asthma
Arthritis
Allergies
Anemia
Alcoholism
Bleeding tendencies
Cancer/ Tumors
Colitis
Congenital Heart Failure
Diabetes
Epilepsy
Goiter
High Blood Pressure
Heart Disease
Hay Fever
Insanity
Kidney Disease
Leukemia
Migraines
Nervous Breakdown
Obesity
Rheumatism
Rheumatic Fever
Stroke
Suicidal Tendencies
Stomach Ulcers
Tuberculosis (TB)
Thyroid

If there are any other conditions present in your family history that were not listed above, please list them below
Your Health History
Major hospitalizations or illness
Operations (type and year)
Disease or illness requiring hospitalization (condition and year)
Describe any serious injuries or accidents you have had (include the year)
Drugs or foods you are allergic to
Medications you are currently taking

AntibioticsAspirin, Tylenol etcBarbituratesBirth control pillsBlood thinnersCortisoneCough medicationDigitalisDilantinInsulin or diabetic medicationIron or poor blood medicationLaxativesMedical marijuana (CBD or CBD/THC oils)Recreational marijuanaPhenobarbitalSleeping pillsThyroid medicationsTranquilizersWeight reductions pills
Are you currently taking natural or synthetic hormones?

Natural hormonesSynthetic hormones
Please list any hormones you are taking
Please list all other medications below
Do you take any vitamins or supplements? (Please list below)
Please check any problems that you are currently experiencing

AllergiesAlcoholismAnemiaAngina PectorisArthritisBladder diseaseBleeding gumsBleeding tendencyBrittle nailsBronchitisBruise easilyCancerChicken PoxChildhood HyperactivityCold hands/feetDiabetesDandruff/dry scalpDepressionDizzinessEczemaEdemaEmphysemaEye infectionEpilepsyFar sightedForgetfulnessGallstonesGerman measlesGoiterGrinding teethGum problemsHay feverHearing lossHeart diseaseHerpes simplexHemorrhoidsHepatitisHigh blood pressureHives/rashesInsomniaKidney diseaseKidney stonesLeukemiaLiver diseaseLow blood pressureMalariaMigrainesMononucleosisMumpsNear sightedNervous breakdownNeuralgia/NeuritisNight sweatsNightmaresOsteoporosisPalpitationsPerspire easilyPneumoniaPolioReduced sexual energyRheumatic feverRheumatismRinging in the ears/TinnitusScarlet feverSciaticaSores in the mouthStrokeStomach ulcersTension/anxietyTonsillitisTuberculosisThyroid conditionVenereal diseaseVivid dreamsWeakness/numbness in legs
Please check any problems that you have experienced in the past

AllergiesAlcoholismAnemiaAngina PectorisArthritisBladder diseaseBleeding gumsBleeding tendencyBrittle nailsBronchitisBruise easilyCancerChicken PoxChildhood HyperactivityCold hands/feetDiabetesDandruff/dry scalpDepressionDizzinessEczemaEdemaEmphysemaEye infectionEpilepsyFar sightedForgetfulnessGallstonesGerman measlesGoiterGrinding teethGum problemsHay feverHearing lossHeart diseaseHerpes simplexHemorrhoidsHepatitisHigh blood pressureHives/rashesInsomniaKidney diseaseKidney stonesLeukemiaLiver diseaseLow blood pressureMalariaMigrainesMononucleosisMumpsNearsightedNervous breakdownNeuralgia/NeuritisNight sweatsNightmaresOsteoporosisPalpitationsPerspire easilyPneumoniaPolioReduced sexual energyRheumatic feverRheumatismRinging in the ears/TinnitusScarlet feverSciaticaSores in the mouthStrokeStomach ulcersTension/anxietyTonsillitisTuberculosisThyroid conditionVenereal diseaseVivid dreamsWeakness/numbness in legs
Have you ever had a panic/anxiety attack?

YesNo
If "Yes", how often do you experience panic/anxiety attacks?

YearlyMonthlyWeeklyDailyInfrequently
How many times in the given period above do you have an attack(s)?
Diet
Vegetarian

YesNo
Vegan

YesNo
Halal

YesNo
Kosher

YesNo
Gluten Intolerance

YesNo
Celiac Disease

YesNo
Red meat

YesNo
Fish

YesNo
Poultry/Fowl

YesNo
Dairy

YesNo
Eggs

YesNo
What time of day do you eat breakfast

:HourMinutesAM/PM Option
What time of day do you eat lunch?

:HourMinutesAM/PM Option
What time of day do you eat supper?

:HourMinutesAM/PM Option
Please check any problems you are currently experiencing

Abdominal bloatingAbdominal painAnorexia/bulimiaBelchingBleeding from rectumColitisConstipationDiarrheaDifficulty swallowingDistress from fatty or greasy foodsFlatulence (gas)HeartburnHypoglycemiaIrritable before mealsNausea/dizzinessObesityPain after eatingPain before eatingRapid weight changeStomach/duodenal cancerTired after eatingUnderweight
Please check any problems you have experienced in the past

Abdominal bloatingAbdominal painAnorexia/bulimiaBelchingBleeding from rectumColitisConstipationDiarrheaDifficulty swallowingDistress from fatty or greasy foodsFlatulence (gas)HeartburnHypoglycemiaIrritable before mealsNausea/dizzinessObesityPain after eatingPain before eatingRapid weight changeStomach/duodenal cancerTired after eatingUnderweight
Please list any foods or tastes you have a particular craving for
Please list any foods or tastes you have a particular aversion to
Smoking/drugs

How many cigarettes do you smoke on a daily basis?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many cigars do you smoke on a daily basis?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many times per week do you smoke marijuana?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

Have you ever done Ayahuasca?

YesNo
When you took Ayahuasca, did you experience any adverse effects?
Have you ever done hard drugs?

YesNo
What drugs have you done and are you currently still taking hard drugs?
Have you ever taken, or are currently taking, any Benzodiazepines? (including but not limited to: nitrazepam, diazepam (Valium), Lorazepam, Clonazepam (Klonopin), chlordiazepoxide, temazepam, triazolam, oxazepam, alprazolam (Xanax)

YesNo
If you selected "yes" above, please list what type(s) of benzodiazepines you used and for how long you took them for
Drinking

How many times per week do you drink hard liquor?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many times per week do you drink beer?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many times per week do you drink wine?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many times per week do you drink coffee?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many times per week do you drink soft drinks?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

Please describe your program of physical fitness
Please list any hobbies or recreational interests
Please list those areas of your body in which you experience pain
Choose one or two emotions that seem to predominate in your life (frequently experienced, difficult to express, or in some ways influential)
Please indicate approximate dates and briefly describe the nature of any traumatic experiences you have had (divorce, change of residence, injury, death in the family, bankruptcy, etc).
What type of acute illnesses have you had and roughly how often have you experienced them in the last 2 years
Females only
Date of your last menstrual cycle

MonthDayYear
Date

How many days does you period last?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How many days is your monthly cycle?
Age you first began to menstruate?
Please check any of the problems you are currently experiencing with your menstrual cycle

Bleeding/spotting between periodsBleeding occasionally after intercourseBlood clots with periodBreast lumpCramping before periodCramping during periodGenital burningGenital herpesHeavy bleeding with periodInfertilityOvarian cystPain during intercoursePelvic inflammatory diseasePMSUTI (urinary tract infection)Vaginal dischargeVaginal itchingYeast infection
Please check any of the problems you have experienced with your menstrual cycle in the past

Bleeding/spotting between periodsBleeding occasionally after intercourseBlood clots with periodBreast lumpCramping before periodCramping during periodGenital burningGenital herpesHeavy bleeding with periodInfertilityOvarian cystPain during intercoursePelvic inflammatory diseasePMSUTI (urinary tract infection)Vaginal dischargeVaginal itchingYeast infection
Do you get an annual pap smear

YesNo
Have you had a hysterectomy?

YesNo
Number of miscarriages?
Number of abortions?
Number of stillbirths?
Number of children?
How old are your children?
Any complications during or from pregnancy?
Are you currently taking birth control?

YesNo
How long have you been taking birth control?
Did you ever take birth control?
When did you take it and for how long?
If you have never used the birth control pill, have you used other types of contraceptives?
Have you started menopause?

YesNo
How old were you when you started menopause?
Males only
Please check any problems that you are currently experiencing

Burning sensation while urinatingDischarge from penisDribbling after urinationHerniaLoss of sexual activityNocturnal emissionPremature ejaculationProstate issuesSwelling or lumps on the testiclesWeak or slow urine stream
Please check any problems that you have experienced in the past

Burning sensation while urinatingDischarge from penisDribbling after urinationHerniaLoss of sexual activityNocturnal emissionPremature ejaculationProstate issuesSwelling or lumps on the testiclesWeak or slow urine stream
Everyone
Finally, please provide any information about yourself or some condition that might not have been covered
I hereby acknowledge that all the information I have provided above is true and accurate.

YesNo
I HEREBY ACKNOWLEDGE AND UNDERSTAND THAT I AM SEEING A HEALTH COUNSELOR AND IN NO WAY IS THE COUNSELLING DIAGNOSTIC OR PRESCRIBING ADVICE

YesNo
Today's date

MonthDayYear
Date
Please sign below to indicate all the information above is accurate and truthful. To sign on a laptop or PC click and hold the mouse or mousepad down and sign. To sign on a smartphone or tablet use your finger to create you signature.*

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24 HOUR CANCELLATION & PUNCTUALITY POLICY

At Senses of the Soul Ltd our main focus is the quality of care we give. The information on this sheet is designed to best enable us to do that with your cooperation.

CANCELLATION POLICY:
We enforce a strict 24 hour cancellation policy. You will receive an email and text reminder of your appointment, which will also allow you to change or cancel your appointment if necessary. Please make sure to update your email and cell number information so you continue to receive your appointment reminders. Appointments not cancelled within 24 hours will be charged a $90.00 cancellation fee for adult appointments and $80.00 for a child or wise person appointments. Thank you in advance

PUNCTUALITY POLICY:
Our priority is to spend quality time with our clients. In order to accomplish this we schedule the appropriate time needed for each person, and do not overbook, nor do we "squeeze in" extra patients during your time. We cannot, therefore, accommodate a late patient. We respect each patients time. When one patient is late, we will not make the next patient wait. If you are late to your appointment, our practitioner may not be able to see you and you will be responsible for the payment in full. With this in mind, please leave a generous amount of time for traffic irregularities.

We practice these policies because we have found them to benefit all of our clients. These policies help us maintain the integrity we feel is reflected in your experience at Senses of the Soul Ltd.

PLEASE BE CLEAR, BY SIGNING THIS AGREEMENT YOU ARE CONSENTING TO COMPLY WITH THESE POLICIES.
We thank you for being in agreement with us for the best way to serve you and look forward to a mutually productive a positive experience.
Today's date

MonthDayYear
Date
Please sign below to indicate you are aware of the policies of Senses of the Soul stated above and will comply with them. To sign on a laptop or PC click and hold the mouse or mousepad down and sign. To sign on a smartphone or tablet use your finger to create you signature.*

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Senses of the Soul Health History Questionnaire

Personal Information

Family History

Mother

Father

General Family History

Your Health History

Diet

Smoking/drugs

Drinking

Females only

Males only

Everyone