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.

- I will be looking at your nails, tongue and eyes, so please remove nail polish on your hands and do not wear perfume to your initial appointment.

Blessings,
Samantha

Samantha Orthlieb
Master Herbalist, Iridologist
Flower/Nature Essence Therapist
EAV Practitioner, BioEnergetic Medicine

Senses of the Soul Ltd
1 - 587 - 899 - SOUL (7685)
Unit 5, 70 Railway Street East
Cochrane, AB, T4C 2B5
samantha@sensesofthesoul.ca
www.sensesofthesoul.ca
Personal Information
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Age
Height
Weight
Occupation
Date of Birth

Month Day Year
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?

Yes No
What are you being treated for:
Are you presently being treated by any alternative modes of healing

Yes No
What type of alternative modes are you trying:
Family History
Mother
Is your mother living?

Yes No
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?

Yes No
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

Antibiotics Aspirin, Tylenol etc Barbiturates Birth control pills Blood thinners Cortisone Cough medication Digitalis Dilantin Insulin or diabetic medication Iron or poor blood medication Laxatives Medical marijuana (CBD or CBD/THC oils) Recreational marijuana Phenobarbital Sleeping pills Thyroid medications Tranquilizers Weight reductions pills
Are you currently taking natural or synthetic hormones?

Natural hormones Synthetic 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

Allergies Alcoholism Anemia Angina Pectoris Arthritis Bladder disease Bleeding gums Bleeding tendency Brittle nails Bronchitis Bruise easily Cancer Chicken Pox Childhood Hyperactivity Cold hands/feet Diabetes Dandruff/dry scalp Depression Dizziness Eczema Edema Emphysema Eye infection Epilepsy Far sighted Forgetfulness Gallstones German measles Goiter Grinding teeth Gum problems Hay fever Hearing loss Heart disease Herpes simplex Hemorrhoids Hepatitis High blood pressure Hives/rashes Insomnia Kidney disease Kidney stones Leukemia Liver disease Low blood pressure Malaria Migraines Mononucleosis Mumps Near sighted Nervous breakdown Neuralgia/Neuritis Night sweats Nightmares Osteoporosis Palpitations Perspire easily Pneumonia Polio Reduced sexual energy Rheumatic fever Rheumatism Ringing in the ears/Tinnitus Scarlet fever Sciatica Sores in the mouth Stroke Stomach ulcers Tension/anxiety Tonsillitis Tuberculosis Thyroid condition Venereal disease Vivid dreams Weakness/numbness in legs
Please check any problems that you have experienced in the past

Allergies Alcoholism Anemia Angina Pectoris Arthritis Bladder disease Bleeding gums Bleeding tendency Brittle nails Bronchitis Bruise easily Cancer Chicken Pox Childhood Hyperactivity Cold hands/feet Diabetes Dandruff/dry scalp Depression Dizziness Eczema Edema Emphysema Eye infection Epilepsy Far sighted Forgetfulness Gallstones German measles Goiter Grinding teeth Gum problems Hay fever Hearing loss Heart disease Herpes simplex Hemorrhoids Hepatitis High blood pressure Hives/rashes Insomnia Kidney disease Kidney stones Leukemia Liver disease Low blood pressure Malaria Migraines Mononucleosis Mumps Nearsighted Nervous breakdown Neuralgia/Neuritis Night sweats Nightmares Osteoporosis Palpitations Perspire easily Pneumonia Polio Reduced sexual energy Rheumatic fever Rheumatism Ringing in the ears/Tinnitus Scarlet fever Sciatica Sores in the mouth Stroke Stomach ulcers Tension/anxiety Tonsillitis Tuberculosis Thyroid condition Venereal disease Vivid dreams Weakness/numbness in legs
Have you ever had a panic/anxiety attack?

Yes No
If "Yes", how often do you experience panic/anxiety attacks?

Yearly Monthly Weekly Daily Infrequently
How many times in the given period above do you have an attack(s)?
Diet
Vegetarian

Yes No
Vegan

Yes No
Halal

Yes No
Kosher

Yes No
Gluten Intolerance

Yes No
Celiac Disease

Yes No
Red meat

Yes No
Fish

Yes No
Poultry/Fowl

Yes No
Dairy

Yes No
Eggs

Yes No
What time of day do you eat breakfast

: Hour Minutes AM/PM Option
What time of day do you eat lunch?

: Hour Minutes AM/PM Option
What time of day do you eat supper?

: Hour Minutes AM/PM Option
Please check any problems you are currently experiencing

Abdominal bloating Abdominal pain Anorexia/bulimia Belching Bleeding from rectum Colitis Constipation Diarrhea Difficulty swallowing Distress from fatty or greasy foods Flatulence (gas) Heartburn Hypoglycemia Irritable before meals Nausea/dizziness Obesity Pain after eating Pain before eating Rapid weight change Stomach/duodenal cancer Tired after eating Underweight
Please check any problems you have experienced in the past

Abdominal bloating Abdominal pain Anorexia/bulimia Belching Bleeding from rectum Colitis Constipation Diarrhea Difficulty swallowing Distress from fatty or greasy foods Flatulence (gas) Heartburn Hypoglycemia Irritable before meals Nausea/dizziness Obesity Pain after eating Pain before eating Rapid weight change Stomach/duodenal cancer Tired after eating Underweight
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?

Yes No
When you took Ayahuasca, did you experience any adverse effects?
Have you ever done hard drugs?

Yes No
What drugs have you done and are you currently still taking hard drugs?
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

Month Day Year
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 periods Bleeding occasionally after intercourse Blood clots with period Breast lump Cramping before period Cramping during period Genital burning Genital herpes Heavy bleeding with period Infertility Ovarian cyst Pain during intercourse Pelvic inflammatory disease PMS UTI (urinary tract infection) Vaginal discharge Vaginal itching Yeast infection
Please check any of the problems you have experienced with your menstrual cycle in the past

Bleeding/spotting between periods Bleeding occasionally after intercourse Blood clots with period Breast lump Cramping before period Cramping during period Genital burning Genital herpes Heavy bleeding with period Infertility Ovarian cyst Pain during intercourse Pelvic inflammatory disease PMS UTI (urinary tract infection) Vaginal discharge Vaginal itching Yeast infection
Do you get an annual pap smear

Yes No
Have you had a hysterectomy?

Yes No
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?

Yes No
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?

Yes No
How old were you when you started menopause?
Males only
Please check any problems that you are currently experiencing

Burning sensation while urinating Discharge from penis Dribbling after urination Hernia Loss of sexual activity Nocturnal emission Premature ejaculation Prostate issues Swelling or lumps on the testicles Weak or slow urine stream
Please check any problems that you have experienced in the past

Burning sensation while urinating Discharge from penis Dribbling after urination Hernia Loss of sexual activity Nocturnal emission Premature ejaculation Prostate issues Swelling or lumps on the testicles Weak 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.

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

Yes No
Today's date

Month Day Year
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. *

Clear
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

Month Day Year
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. *

Clear
Should be Empty: