initial client questionnaire
So excited to be working with you! Please fill out this questionnaire thoroughly so that....
Date of Birth
Date of Birth
Place of Birth
Would you like for your weight to be different? If so, what?
How many hours do you work each week?
Describe your working environment
Do you have children? If so, how many?
Blood type [if known]
What are some of your favorite things to do outside of work?
What are your health concerns? [List as many details as possible]
What would you like to accomplish and gain from our work together?
Do you sleep well? Do you wake in the night?
What time do you go to bed at night?
What time do you generally wake up and how do you feel upon rising?
Do you drink caffeinated drinks? If so, how much and how often?
Do you smoke? If so, how much and how often?
Do you drink alcohol? If so, how much and how often?
Do you drink soda [diet or regular]? If so, how much and how often?
What role does exercise play in your life?
Have you been exposed to toxic substances at work or at home?
How much water do you drink per day?
Do you have any allergies?
Are you currently taking any vitamins/minerals/herbs/homeopathic remedies, prescription/non-prescription medications, aspirin, laxatives, diet pills, or any other supplements? Please list all below including name brands and amounts.
Do you have any known allergies to medications or herbs? Please list them here.
Are you currently under a Practitioner's care for a specific health issue?
If so, what treatments are you undergoing?
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and the date:
What were your eating habits as a child? [list the types of food]
What percentage of your food is home cooked?
How often do you eat out?
What are the three worst foods you eat each week?
Do you crave sugar?
Do you crave salt?
Do you feel tired or bloated after meals?
Do you feel excessively hungry?
Do you have a poor appetite?
Family Medical History: Heart Disease, Diabetes, Kidney Disease, Arthritis, Asthma, Gallbladder Disease, Cancer, Stomach/Intestinal Disorder? List and explain.
PLEASE NOTE: QUESTIONS BELOW ARE FOR WOMEN ONLY
Are your periods regular?
How many pregnancies have you had?
Do you experience PMS? Is it mild or severe?
Are you peri-menopausal? When did this change first occur?
Are you menopausal? When was your last period?
List your symptoms of peri-menopause:
How many children have you delivered and how were they born? [vaginally/cesarean] Were there complications associated with these births?
Did you receive antibiotics during labor?
Questions? never hesitate
Initial Client Questionnaire - Banner
Initial Client Questionnaire - Intro
Initial Client Interview
Initial Client Questionnaire - Email