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Client Health Consultation Survey

Collect a client's personal details, body measurements, sleep and eating habits, family history, and a review of body systems ahead of a holistic health consultation.

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Page 1

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Full Name*

Nombre

Apellido

Birth Date*

Email*

Skype Email

Phone Number

Height*

Weight*

Waist Circumference*

Confirmation*

I confirm the information provided is accurate

What are the main reasons you are seeking health care advice?*

Weight management Managing a chronic illness Stress or anxiety Digestive issues Low energy or fatigue Preventive checkup

What are your major health concerns?*

Have you been diagnosed with a condition related to your concern(s)?

Yes No

What are your health goals?*

How committed are you to healing yourself and changing your lifestyle?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

How do you rate your current level of health?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

How do you rate your current level of energy or vitality?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

How do you rate your current stress levels?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Do you have trouble falling asleep?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

How many hours of sleep do you get a night?*

Do you wake often, or get woken easily?*

Do you have to go to the bathroom during the night?*

How often during the night?*

Do you snore or have breathing problems during sleep?*

Do you have any known allergies?*

Please list any known allergies

What herbs, vitamins, supplements, or medications are you taking?*

Do you engage in physical activity on a regular basis?

Yes No

In general, what has been your mental state over the last 48 hours?

Excellent Good Fair Poor

Do you smoke?

Yes No

Do you drink caffeine?

Yes No

Do you drink alcohol?

Yes No

Does a member of your household drink alcohol, smoke, or drink caffeine?

Yes No

Do you feel you get enough sleep?

Yes No

What foods have you eaten in the last 24 hours? Please include as many as possible and how they were prepared.

Which natural health products and therapies do you use or have used in the past?

Acupuncture Chiropractic Homeopathy Herbal medicine Massage therapy Meditation or yoga

Page 2

Family History

Please answer as accurately as possible.

Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?

Page 3

Review of Systems

Check any symptoms you have experienced for each system.

Cardiovascular System

Chest pain High blood pressure Palpitations Swelling None

When?