New Client Information Form



CLIENT QUESTIONNAIREThis form may take an hour to complete because it is very comprehensive. Completion of this form is required before a service can be scheduled. This form will help significantly reduce the amount of time typically used during a client-paid session to go over introductory information thereby saving the client money and allowing the client-paid sessions to work on more advanced issues. Please be as honest as possible and provide as much information as possible to ensure an accurate and productive assessment. You can skip any question that does not apply to you or a child (if you are a parent or guardian completing the form for a child). All information provided by client in this questionnaire, over the phone, or during any consultations or sessions will be kept strictly confidential.Section 1ServicesServices Requested: FORMCHECKBOX HYPERLINK "; Holistic Health Consultation FORMCHECKBOX HYPERLINK "; Life/Health/Spiritual Coaching 2) Reason for requesting this service(s): FORMTEXT?????3) Whom may we thank for referring you? FORMTEXT?????Section 2Contact Information1) First Name: FORMTEXT????? Middle Name: FORMTEXT????? Last Name: FORMTEXT????? Name on Birth Certificate (name given at birth): FORMTEXT????? 2) Email Address: FORMTEXT????? Home Address: FORMTEXT????? City: FORMTEXT????? State: FORMTEXT????? Zip: FORMTEXT?????3) Home Phone: ( FORMTEXT ?????) FORMTEXT ?????- FORMTEXT ????? Cell Phone: FORMTEXT?????) FORMTEXT ?????- FORMTEXT ????? Work Phone: FORMTEXT ?????) FORMTEXT ?????- FORMTEXT ?????4) Living Situation: FORMCHECKBOX Alone FORMCHECKBOX Friends FORMCHECKBOX Partner FORMCHECKBOX Spouse FORMCHECKBOX Parents FORMCHECKBOX Children FORMCHECKBOXPets FORMCHECKBOX Other: FORMTEXT?????5) Occupation: FORMTEXT????? FORMCHECKBOXFull-time FORMCHECKBOX Part-time Employer/School: FORMTEXT ?????Section 3Physical Health1) Gender: FORMCHECKBOX Male FORMCHECKBOXFemale Date of Birth: FORMTEXTMM/DD/YYYY Age: FORMTEXT?????2) Height: FORMTEXT????? feet FORMTEXT ????? inches Weight: FORMTEXT????? lbs. Waist: FORMTEXT ????? inches3) Current Health Conditions:Health ConditionTreatments Have TriedDiagnosed by Medical Doctor?FORMTEXT?????FORMTEXT?????FORMCHECKBOXFORMTEXT????? FORMTEXT ?????FORMCHECKBOXFORMTEXT?????FORMTEXT?????FORMCHECKBOXFORMTEXT?????FORMTEXT?????FORMCHECKBOXFORMTEXT?????FORMTEXT?????FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Additional Current Health Conditions: FORMTEXT ?????4) Health care or wellness provider (e.g., internal medicine doctor, psychologist/therapist) you are currently working with:Provider NameProvider TypeReason for Seeing FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional Providers: FORMTEXT ?????5) Prescription and over-the-counter drugs you are currently taking:Drug NameReason for Taking ThemDosageFrequency FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional Drugs: FORMTEXT ?????6) Supplements (e.g., vitamins, minerals, herbs, enzymes, probiotics, protein powders) you are currently taking:Supplement Brand & NameReason for Taking ThemDosageFrequency FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional Supplements: FORMTEXT ?????7) Please check all symptoms below that you are currently experiencing or have experienced recently:Cardiovascular FORMCHECKBOX High blood pressure FORMCHECKBOX Low blood pressure FORMCHECKBOX Pain in heart FORMCHECKBOX Poor circulation FORMCHECKBOX Swelling FORMCHECKBOX Stroke/murmur FORMCHECKBOX Other: FORMTEXT ?????Skin FORMCHECKBOX HYPERLINK "; Boils FORMCHECKBOX Bruises FORMCHECKBOX Dryness FORMCHECKBOX Itching FORMCHECKBOX HYPERLINK "; Varicose veins FORMCHECKBOX Skin eruptions FORMCHECKBOX Other: FORMTEXT ?????Muscles/Joints FORMCHECKBOX Backache FORMCHECKBOX Broken bones FORMCHECKBOX Limited mobility FORMCHECKBOX Arthritis FORMCHECKBOX HYPERLINK "; Bursitis FORMCHECKBOX Weakness FORMCHECKBOX Other: FORMTEXT ?????Respiratory FORMCHECKBOX Chest pain FORMCHECKBOX Difficulty breathing FORMCHECKBOX Cough FORMCHECKBOX Wheezing FORMCHECKBOX HYPERLINK "; Tuberculosis FORMCHECKBOX Congestion FORMCHECKBOX Itchy ears/eyes FORMCHECKBOX HYPERLINK "; Asthma FORMCHECKBOX Coughing up blood FORMCHECKBOX Other: FORMTEXT ?????Urinary/Kidney FORMCHECKBOX Excessive urination FORMCHECKBOX Water retention FORMCHECKBOX Burning urine FORMCHECKBOX HYPERLINK "; Kidney stones FORMCHECKBOX Lower back pain FORMCHECKBOX Circles under eyes FORMCHECKBOX Blood in urine FORMCHECKBOX Other: FORMTEXT ?????Gastro-Intestinal FORMCHECKBOX Belching/Gas FORMCHECKBOX HYPERLINK "; Colitis FORMCHECKBOX Constipation FORMCHECKBOX Diarrhea FORMCHECKBOX Abdominal pain FORMCHECKBOX Liver disorders FORMCHECKBOX HYPERLINK "; Gallstones FORMCHECKBOX HYPERLINK "; Ulcers FORMCHECKBOX Digestive troubles FORMCHECKBOX Other: FORMTEXT ?????Eyes/Ears/Nose/Throat FORMCHECKBOX Ear aches FORMCHECKBOX Hay fever FORMCHECKBOXSore throat FORMCHECKBOX Canker sores FORMCHECKBOX Eye pains FORMCHECKBOX Sinus infections FORMCHECKBOX HYPERLINK "; Tonsillitis FORMCHECKBOX Nosebleeds FORMCHECKBOX Failing eyesight FORMCHECKBOX Sinus congestion FORMCHECKBOX Hearing loss FORMCHECKBOX Difficulty breathing FORMCHECKBOX Other: FORMTEXT ?????GeneralFORMCHECKBOXFatigue FORMCHECKBOX Excessive thirst FORMCHECKBOX Difficulty sleeping FORMCHECKBOX Night sweats FORMCHECKBOX Loss of appetite FORMCHECKBOXIrritability FORMCHECKBOX Fever FORMCHECKBOX Always hungry FORMCHECKBOXCold hands and feet FORMCHECKBOX Other: FORMTEXT ?????Male Reproductive FORMCHECKBOX Burning/discharge FORMCHECKBOX Painful testicles FORMCHECKBOX Lumps/swelling of testicles FORMCHECKBOX Impotence FORMCHECKBOX HYPERLINK "; Vasectomy FORMCHECKBOX Other: FORMTEXT ?????Female Reproductive FORMCHECKBOX Heavy bleeding FORMCHECKBOX Unusual vaginal discharge FORMCHECKBOX Painful intercourse FORMCHECKBOX Breast pain FORMCHECKBOX Infertility FORMCHECKBOXMood Swings FORMCHECKBOXIrregular cycles FORMCHECKBOX Blood clots FORMCHECKBOX Vaginal itching FORMCHECKBOX Vaginal dryness FORMCHECKBOX Breast lumps FORMCHECKBOX HYPERLINK "; Genital herpes FORMCHECKBOX HYPERLINK "; PMS FORMCHECKBOX HYPERLINK "; Pre-menopausal FORMCHECKBOX Menopause FORMCHECKBOX Pelvic pain FORMCHECKBOX HYPERLINK "; Anemia FORMCHECKBOX HYPERLINK "; Hot flashes FORMCHECKBOX Other: FORMTEXT ?????8) Medical History (major health problems, accidents, injuries, and all surgeries/operations/abortions):ProblemYear(s) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional Medical History: FORMTEXT ?????9) Please list all medication, herbs, food, and environmental factors to which you have a known allergy: FORMTEXT ?????10) Do you have less than 20/20 vision? FORMCHECKBOX Yes FORMCHECKBOXNoIf answered Yes above, what do you wear? FORMCHECKBOX Eye Glasses FORMCHECKBOX Contact Lens FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX NothingReason for wearing them: FORMCHECKBOX Nearsighted FORMCHECKBOX Farsighted FORMCHECKBOX HYPERLINK "; Presbyopia FORMCHECKBOX HYPERLINK "; Astigmatism FORMCHECKBOX HYPERLINK "; Cataracts FORMCHECKBOX Other: FORMTEXT ?????11) HYPERLINK "; Amalgam Fillings? FORMCHECKBOXI have them in my teeth now. FORMCHECKBOX I had them in the past, but not now. FORMCHECKBOX I never had any. HYPERLINK "; Root Canals? FORMCHECKBOXYes, I had them done in the past. FORMCHECKBOX No, I never had them done.If answered Yes, how many have you had? FORMTEXT ?????Please describe any current problems with your teeth and gums: FORMTEXT ?????12) HYPERLINK "; \l "schedules" Vaccinated? FORMCHECKBOXAt ages 0-6 years FORMCHECKBOXAt ages 7-18 years FORMCHECKBOX At ages 19 to ≥65 years FORMCHECKBOX Never been vaccinatedVaccination Type(s): FORMCHECKBOX Standard childhood vaccines FORMCHECKBOX Annual flu shots FORMCHECKBOX Other: FORMTEXT ?????13) Please provide the information requested for each of the foods below you consume:Brand/Source/Type/KindAmountFrequencyCoffee FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tea FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Energy sports drinks FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Carbonated water/juice FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sodas FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Alcoholic beverages FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Fruit juice FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Dairy (milk, cheese, yogurt) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Eggs FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Seafood (fish, shellfish, etc.) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Bread/tortillas/pita FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Pasta/noodles FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Crackers/chips FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Pastries (cookies, cake, etc.) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Beans FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Soy products FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Corn products FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Nuts FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Seeds FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Garlic/onions FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tomatoes FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Potatoes FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Bell Peppers FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Chili Peppers (any kind) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Eggplant FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Salt FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Cooking oil FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????White sugar FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Brown sugar FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Diet sweeteners FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Honey FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Maple syrup FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Molasses FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Stevia FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14) What and when do you normally eat and drink for:Food, Quantity, Quality, Brand/SourceTime EatenBreakfast: FORMTEXT ????? FORMTEXT ?????Morning Snack: FORMTEXT ????? FORMTEXT ?????Lunch: FORMTEXT ????? FORMTEXT ?????Afternoon Snack: FORMTEXT ????? FORMTEXT ?????Dinner: FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ?????15) Please list any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) including time of day or month: FORMTEXT ?????16) Approximately what percentage of your food do you normally eat raw in a day? FORMTEXT ?????%17) Approximately what percentage of the food you normally eat in a day is organic (free of pesticides, herbicides, fungicides, nematicides, genetically modified ingredients)? FORMTEXT ?????%18) How often do you eat from fast-food restaurants? FORMTEXT ?????How often do you eat from other types of restaurants? FORMTEXT ?????Please list the restaurants you like to frequent here: FORMTEXT ?????If client is a child, does the child eat lunch provided by the school? FORMCHECKBOX Yes FORMCHECKBOX No19) What is your nutritional or metabolic type? Please take the free HYPERLINK "; Nutritional Typing test to find out (if you have not done this before) and then record your type here. FORMCHECKBOX Veggie/Carbo Type FORMCHECKBOX Mixed Type FORMCHECKBOX Protein Type20) How much water do you typically drink each day? FORMTEXT ?????Type of the water you typically drink: FORMCHECKBOX Tap water FORMCHECKBOXDistilled water FORMCHECKBOX Activated carbon filtered water FORMCHECKBOXReverse Osmosis filtered water FORMCHECKBOX Ionized alkaline water FORMCHECKBOX Spring water FORMCHECKBOX Other type of water: FORMTEXT ?????What is the water container or bottle made of that you typically drink from or store the water in (please check all that apply)? FORMCHECKBOX Plastic FORMCHECKBOXStainless Steel FORMCHECKBOX Aluminum FORMCHECKBOXGlass FORMCHECKBOX Ceramic/Porcelain FORMCHECKBOX Other: FORMTEXT ?????If you buy your water, what brand do you buy? FORMTEXT ?????Do you have a whole house water purification system? FORMCHECKBOX Yes FORMCHECKBOXNo Brand: FORMTEXT ?????Do you have a shower water filter? FORMCHECKBOX Yes FORMCHECKBOXNo Brand: FORMTEXT ?????21) Please describe your typical bowel movements:Frequency? FORMTEXT ?????Amount? FORMTEXT ?????Color? FORMTEXT ?????Offensive odor (smelly)? FORMTEXT ?????Float to the top or sink to the bottom? FORMTEXT ?????Type? (see HYPERLINK "; chart and choose a type) FORMTEXT ?????22) Check all the types of pots, pans, cookware, bakeware, rice cookers, crock pots (slow cookers), grills, coffee pots, tea kettles, etc. you use to cook your food. The materials below refer to the part of the cookware that comes in contact with food: FORMCHECKBOX Aluminum FORMCHECKBOX Iron FORMCHECKBOXGlazed ceramic, porcelain enamel, or clay FORMCHECKBOX Anodized aluminum FORMCHECKBOX Copper FORMCHECKBOX Unglazed clay FORMCHECKBOXNon-stick coating (Teflon or other) FORMCHECKBOX Glass FORMCHECKBOX Silicone FORMCHECKBOXStainless steel FORMCHECKBOX Plastic FORMCHECKBOX Stone FORMCHECKBOX Other type: FORMTEXT ?????Check all the types of dishware, tupperware, cups, utensils, food preparation tools you use to prepare, serve, eat and drink from. The materials below refer to the part that comes in contact with food: FORMCHECKBOXAluminum FORMCHECKBOXPlastic FORMCHECKBOXGlazed ceramic, porcelain, or clay FORMCHECKBOXStainless steel FORMCHECKBOXGlass FORMCHECKBOX Lead Crystal Glass FORMCHECKBOX Unglazed clay FORMCHECKBOX Copper FORMCHECKBOXWood FORMCHECKBOXSilicone FORMCHECKBOX Silver FORMCHECKBOX Stone FORMCHECKBOX Other type: FORMTEXT ?????23) Please indicate the brand/product of the personal care items you use:Brand/ProductToothpaste FORMTEXT ?????Mouth rinse FORMTEXT ?????Floss FORMTEXT ?????Shampoo FORMTEXT ?????Conditioner FORMTEXT ?????Soap bar, bath/shower gel FORMTEXT ?????Facial cleanser FORMTEXT ?????Shaving cream FORMTEXT ?????After shave FORMTEXT ?????Hand soap FORMTEXT ?????Body lotion/cream/mineral oil FORMTEXT ?????Facial cream/moisturizer FORMTEXT ?????Lip balm (chapstick) FORMTEXT ?????Talc or baby powder FORMTEXT ?????Sunscreen/sunblock FORMTEXT ?????Bug repellant FORMTEXT ?????Deodorant FORMTEXT ?????Perfume/cologne FORMTEXT ?????Makeup foundation FORMTEXT ?????Lipstick/lipgloss FORMTEXT ?????Eye shadow FORMTEXT ?????Mascara FORMTEXT ?????Eye liner FORMTEXT ?????Blush FORMTEXT ?????Hair spray/gel FORMTEXT ?????Tampons FORMTEXT ?????Sanitary Napkins FORMTEXT ?????Other personal care items: FORMTEXT ?????24) Please indicate the brand/product of the household or cleaning items you use:Brand/ProductLaundry detergent FORMTEXT ?????Fabric softener FORMTEXT ?????Laundry bleaching agent FORMTEXT ?????Laundry stain remover FORMTEXT ?????Dishwashing liquid FORMTEXT ?????Dishwasher detergent FORMTEXT ?????Dishwasher rinse aid FORMTEXT ?????Toilet bowl cleaner FORMTEXT ?????Bathroom cleaner FORMTEXT ?????Drainer/unclogger FORMTEXT ?????Kitchen cleaner FORMTEXT ?????Silver polish FORMTEXT ?????Glass/mirror cleaner FORMTEXT ?????Wood polisher FORMTEXT ?????Hard floor cleaner FORMTEXT ?????Floor wax FORMTEXT ?????Carpet stain remover FORMTEXT ?????Carpet cleaning FORMTEXT ?????Oven/stove cleaner FORMTEXT ?????Air freshener FORMTEXT ?????Sponge FORMTEXT ?????Pesticide/Insecticide FORMTEXT ?????Fumigation/pesticide bombs FORMTEXT ?????Flea collar FORMTEXT ?????Herbicide/weed killers FORMTEXT ?????Fertilizer FORMTEXT ?????Chlorine/bromine for pool/spa FORMTEXT ?????Other household or cleaning items: FORMTEXT ?????25) Have you ever lived in a place that was built before 1980? FORMCHECKBOX Yes FORMCHECKBOX NoIf answered Yes, approximately how long did you lived in these places in total? FORMTEXT ?????26) Do you smoke, chew tobacco, or use nicotine gum/patches? FORMCHECKBOX Yes FORMCHECKBOXNoIf Yes, how much per day? FORMTEXT ?????Are you frequently around people who smoke? FORMCHECKBOX Yes FORMCHECKBOXNo27) If you have done a physical detox before, what kind of detox method did you use and when and how long did you do them? (e.g., fasting, herbal cleanse, colonics, enemas, special detox diet) FORMTEXT ?????28) Do you live or work near: FORMCHECKBOX HYPERLINK "; Power Lines FORMCHECKBOX HYPERLINK "; Transformers FORMCHECKBOX HYPERLINK "; Substations FORMCHECKBOX HYPERLINK "; Military/Airport Radar Domes FORMCHECKBOX HYPERLINK "; Microwave TowersWhich of the following do you use? FORMCHECKBOXMicrowave oven FORMCHECKBOXCell phone/smartphone FORMCHECKBOX Cordless phone FORMCHECKBOXWireless network (WIFI) FORMCHECKBOX Alarm clock FORMCHECKBOX Bluetooth headset FORMCHECKBOXiPad or other wireless device FORMCHECKBOXLaptop computer/netbook FORMCHECKBOXDesktop computer FORMCHECKBOX Fluorescent lights FORMCHECKBOX Full-spectrum lights FORMCHECKBOX Electric bed-side clock FORMCHECKBOX Telephone/answering machine in bedroom FORMCHECKBOX Water bed FORMCHECKBOXMetal spring/coil mattress FORMCHECKBOX Metal box spring foundation FORMCHECKBOX Metal frame bottom/head board FORMCHECKBOX Electric blanket FORMCHECKBOX Electric razors FORMCHECKBOXHair dryer FORMCHECKBOX Electric toothbrush FORMCHECKBOX Quart analog wrist watch FORMCHECKBOX CRT TV FORMCHECKBOXPlasma TV FORMCHECKBOXLCD TV FORMCHECKBOXLED TV If you have had any of the following, how often do you get them?FrequencyStandard medical/dental x-rays FORMTEXT ?????Digital medical/dental x-rays FORMTEXT ?????CT scan FORMTEXT ?????Mamogram FORMTEXT ?????Radiation cancer therapy FORMTEXT ?????Other: FORMTEXT ?????29) Exercise:Physical ActivityHow Long?Frequency FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional physical activity: FORMTEXT ?????30) How many hours of sleep do you get each day? FORMTEXT ?????Do you get tired or sleepy during your usual waking hours? FORMCHECKBOXYes FORMCHECKBOX NoAre you exposed to any source of light during sleep? FORMCHECKBOX Nightlight FORMCHECKBOX Street lights FORMCHECKBOX Alarm clock FORMCHECKBOX T.V. FORMCHECKBOX Other: FORMTEXT ?????31) How often and how long do you typically spend time outdoors? FORMTEXT ?????32) How often and how long do you typically expose your skin to direct sunlight without any sunscreen? FORMTEXT ?????33) If you are celibate, how long have you been celibate and what are your reasons for celibacy? FORMTEXT ?????34) If you are sexually active, how often do you engage in sexual activity with or without a partner? FORMTEXT ????? Which of the following contraceptives do you use? FORMCHECKBOX Oral contraceptives FORMCHECKBOXRhythm-method FORMCHECKBOX I.U.D. FORMCHECKBOX Diaphragm FORMCHECKBOX Condoms FORMCHECKBOX Mucous-method FORMCHECKBOX Cervical Cap FORMCHECKBOX Spermicides FORMCHECKBOX HYPERLINK "; Fertility lens FORMCHECKBOX None35) If female, please provide the following pregnancy and menstruation history:How Many?Year(s)ComplicationsPregnancies FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Miscarriages FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Abortions FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????First Period FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????36) Please use this space to add any other information that you think would be helpful in understanding your physical condition: FORMTEXT ?????Section 4Mental Well-Being1) Marital Status: FORMCHECKBOX Single (not in a relationship) FORMCHECKBOX Single (in a non-committed relationship) FORMCHECKBOXSingle (in a committed relationship) FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Married (monogamous) FORMCHECKBOX Married (polygamous) FORMCHECKBOX Married (non-committed)2) Do you have problems with keeping a relationship commitment (i.e., have had or are currently in an affair)? FORMCHECKBOX Yes FORMCHECKBOX No3) Please list the name of each person you have a significant relationship with (e.g., spouse, relationship partner, children, parent, grandparent, sibling, or other significant family, friends, coworkers), including their age, sex (M/F), whether they are living with you (Y/N):NameRelationshipAgeSexWith You FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT??? FORMTEXT ????? FORMTEXT ?????FORMTEXT???FORMTEXT???FORMTEXT???Additional people: FORMTEXT ?????4) Please describe any concerns or issues with any of the people listed above that are bothering you: FORMTEXT ?????5) Please describe any concerns or issues with other people (or things) not listed above that are bothering you: FORMTEXT ?????6) Please list all bad/traumatic major life events that had a significant emotional/energetic impact on you (e.g., sexual molestation, rape, divorce, surgery, end of a relationship, loss of job, change of residence, injury, death of a loved one, etc.) and their approximate dates:Year(s)Traumatic/Significant Life Event FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FORMTEXT????? FORMTEXT ?????FORMTEXT????? FORMTEXT ?????FORMTEXT????? FORMTEXT ?????FORMTEXT????? FORMTEXT ?????Additional events: FORMTEXT ?????7) How were you born? FORMCHECKBOX Planned C-Section FORMCHECKBOX Emergency C-Section FORMCHECKBOX Breech FORMCHECKBOX Vacuum Extraction FORMCHECKBOX Forceps FORMCHECKBOX Induced Labor FORMCHECKBOX Episiotomy FORMCHECKBOX Cord Around Neck FORMCHECKBOX Premature FORMCHECKBOX Incubator Baby FORMCHECKBOX Water Birth FORMCHECKBOX Midwife Assisted FORMCHECKBOX Normal with No Complications FORMCHECKBOX Fast Delivery FORMCHECKBOX Long/Delayed Delivery FORMCHECKBOX Other: FORMTEXT ?????Where were you born? FORMCHECKBOXIn a Hospital FORMCHECKBOX Birthing Center FORMCHECKBOX At Home FORMCHECKBOX Other: FORMTEXT ?????8) What have you done for emotional healing and removing mental blocks such as fear, negative thoughts or belief systems? FORMCHECKBOXCounseling/psychotherapy FORMCHECKBOXJournaling FORMCHECKBOXAffirmations FORMCHECKBOX Afformations FORMCHECKBOX NLP Therapy FORMCHECKBOX Dianetics Auditing FORMCHECKBOXPrayer FORMCHECKBOXVisualization FORMCHECKBOX Ho'oponopono FORMCHECKBOX Recapitulation FORMCHECKBOX EFT FORMCHECKBOX Diving In FORMCHECKBOX Abraham-Hicks Emotional Guidance Scale FORMCHECKBOX Sedona Method FORMCHECKBOX Hypnosis FORMCHECKBOX The Power Pause FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX None at all9) How many hours of television do you typically watch in a week? FORMTEXT????? What programs do you usually watch? FORMTEXT ?????10) What kind of movies do you like to watch? FORMCHECKBOX Horror FORMCHECKBOX Sci-Fi/Fantasy FORMCHECKBOX X-Rated FORMCHECKBOXComedy FORMCHECKBOXDrama FORMCHECKBOX Foreign FORMCHECKBOXDocumentaries FORMCHECKBOXSpiritual/Religious FORMCHECKBOX Educational11) Please check all the statements below that describe you or are true for you: FORMCHECKBOX I am often not able to express my emotions.FORMCHECKBOX I express my emotions but often in a destructive way.FORMCHECKBOX I am often stressed out and feel overwhelmed. FORMCHECKBOX Even though I'm in a relationship, I often feel lonely.FORMCHECKBOX I often feel anxious and nervous for no good reason.FORMCHECKBOX I don't sleep well at night and have a hard time waking up in the morning.FORMCHECKBOX I often suffer from bad dreams and nightmares. FORMCHECKBOX There are many things I'd like to change in my life. I just don't have the time or means.FORMCHECKBOX I have very low energy and often feel exhausted mentally and physically.FORMCHECKBOX I don't enjoy my work and would rather be doing something else. FORMCHECKBOX I find my children irritating and hard to relate to. FORMCHECKBOX I have very few hobbies, interests, passions, dreams, or goals in life. FORMCHECKBOX I often feel depressed for no reason. FORMCHECKBOX I feel I have very little control over my life--that my life is not happening the way I want it to.FORMCHECKBOX I have a hard time letting go of the past. FORMCHECKBOX I don't look towards the future with much enthusiasm. FORMCHECKBOX I am not able to concentrate for extended periods of time. FORMCHECKBOX My outlook is more negative than positive. FORMCHECKBOX I spend a great deal of time worrying about what people think about me.12) Please use this space to add any other information that you think would be helpful in understanding your mental/emotional condition: Section 5Spiritual Awareness1) What is your faith (and denomination, if applicable)? FORMCHECKBOX Christian: FORMTEXT ????? FORMCHECKBOX Judaism: FORMTEXT ????? FORMCHECKBOX Islam: FORMTEXT ????? FORMCHECKBOX Buddhism: FORMTEXT ????? FORMCHECKBOX Hinduism: FORMTEXT ????? FORMCHECKBOX All Faiths/InterFaith: FORMTEXT ????? FORMCHECKBOX Agnostic: FORMTEXT ????? FORMCHECKBOX Astheist: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????2) Please indicate the specific technique or method of your spiritual practice and how often you practice it:TypeDescription/ExampleHow Often HYPERLINK "; Meditation FORMTEXT ????? FORMTEXT ?????Visualization FORMTEXT ????? FORMTEXT ?????Prayer FORMTEXT ????? FORMTEXT ?????Affirmations FORMTEXT ????? FORMTEXT ?????Afformations FORMTEXT ????? FORMTEXT ????? HYPERLINK "; Pranayama FORMTEXT ????? FORMTEXT ????? HYPERLINK "; Yoga FORMTEXT ????? FORMTEXT ?????Fasting FORMTEXT ????? FORMTEXT ?????Silence Vow FORMTEXT ????? FORMTEXT ?????Celibacy FORMTEXT ????? FORMTEXT ?????Additional spiritual practices: FORMTEXT ?????3) What is your understanding of God or the nature of existence and reality? FORMTEXT ?????4) What do you feel is the meaning or purpose of Life, and what is the meaning and purpose or your life? FORMTEXT ?????5) Beyond your gender, race, profession, title, religion, culture, physical characteristics, and personality, who are you really? FORMTEXT ?????6) Please describe any experiences you have had that led you to the above understanding (e.g., traumatic events, mystical experiences, near-death experiences, out-of-body, past-life recall, etc.): FORMTEXT ?????7) Please check all the statements below that describe you or are true for you:FORMCHECKBOX I tend to see the good in people.FORMCHECKBOX I have a great sense of humor and love a good joke.FORMCHECKBOX I receive great joy from my family.FORMCHECKBOX My outlook on life is positive.FORMCHECKBOX My job uses all my greatest talent. FORMCHECKBOX I have plenty of energy to do all the things I want. FORMCHECKBOX I sleep well at night and feel rested in the morning.FORMCHECKBOX I can concentrate on the task at hand for as long as it takes.FORMCHECKBOX I have a strong spiritual trust in God, the Universe, and my Higher Self to support me and provide all that I need.FORMCHECKBOX I am able to express anger and other negative feelings constructively.FORMCHECKBOX I practice meditation or other relaxation techniques. FORMCHECKBOX I feel deep peace and tranquility.FORMCHECKBOX I have many close friends that I can always count on.FORMCHECKBOX I accept full responsibility for everything that happens to me in my life because I know that I created this life I am living.FORMCHECKBOX I trust my intuition because it is almost always accurate. FORMCHECKBOX I do not harbor any resentment from the past. FORMCHECKBOX I can feel completely fulfilled even if I'm alone.FORMCHECKBOX I have many hobbies, interests, passions, dreams, and goals in life.FORMCHECKBOX How I see myself is more important than how others see me.FORMCHECKBOX I often go out of my way to help others because I often see myself in others and have compassion for them.8) Please use this space to add any other information that you think would be helpful in understanding your spiritual condition: FORMTEXT ?????Section 6Overall Life Assessment1) Please rate the following aspects of your life using the scale provided:1 – Very Bad2 – Poor3 – Okay4 – Good5 – ExcellentPhysical health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual satisfaction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Financial status FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Job/work/career satisfaction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Time to play, relax, enjoy hobbies, etc. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Relationship with family FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Relationship with friends FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOXRelationship with God (level of spiritual enlightenment) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Contribution to the world (realization of life purpose) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2) Please use this space to add any other information about yourself that you think will be helpful: FORMTEXT ?????Section 7Acknowledgement and Acceptance of Terms & Conditions of ServicePlease click this HYPERLINK "; Terms & Conditions of Service link to read the Terms & Conditions of Service before checking the checkbox below. Any form submitted that does not have the box below checked will be returned and considered incomplete.FORMCHECKBOX By checking this box, I acknowledge that I have read and accept the HYPERLINK "; Terms & Conditions of Service and agree to email this completed form as an attachment to HYPERLINK "mailto:ngoc.luzardo@?subject=Client%20Questionnaire" ngoc.luzardo@. The email will serve as my signature of the form verifying that I completed the form to the best of my ability and have accepted its terms and conditions.If you printed this form and completed the paper copy, please sign, print your name, and the date you signed below:____________________________________________________________________________________________SignatureDate Signed_____________________________________________________Printed Name ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download