The Whole Body Renewal Center, LLC



1943100286385Wellness Survey0Wellness Survey Personal Information:Name:________________________________________Address:_______________________________ City, State, Zip_______________________________Home Phone:__________________Cell Phone:__________________E-Mail:______________________________________Preferred Method of Contact (circle one)Home PhoneCell PhoneEmailWould you like to be on a mailing list for seminars and upcoming classes?Yes NoHave a blessed day!JuliannaClient Interview Date:_________________Please answer all questions frankly, to the best of your knowledge. All information is confidential.Name: _____________ Birthdate:_______Gender: M F Height:________ Weight:____________ Blood Pressure (if known):_____Occupation:____________ List your top 5 concerns in order of importance:1. ___________________________________________________ How long? _____________________2. ___________________________________________________ How long? _____________________3. ___________________________________________________ How long? _____________________4. ___________________________________________________ How long? _____________________5. ___________________________________________________ How long? _____________________Overall HealthAre you presently taking any medications and how long you have been taking them? Please List. (Attach sheet if necessary)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you presently taking any nutritional supplements, Vitamins or minerals? If so, please list, as well as where you purchase and what brand. Did you bring them today? If so, please have ready to review.SupplementDoseSource/Brand__________________________________________ _______________________________________________________________________ _____________ ____________________________________________________________________________________ __________________________________________ Tell me about your daily routine. What time do you get up in morning? _____________What do you do when you get up? (Food, drink, exercise, television, etc…) __________________________________________________________________________________________________________________________________________________________________________________________________DIET: What foods do you eat the most? _________________________________________________List foods you dislike. __________________________________________________List foods you never eat. _______________________________________________________________________List foods you crave. __________________________________________________What kinds of fruits and vegetables do you like? _____________________________________________What kinds of fruits and vegetables do you hate? _____________________________________________Are you the first one done at dinner table? YNDo you eat FAST FOOD? If so, how often? ___________Do you eat more meat, carbs or veg/fruits? __________________________________________________Do you drink pop/soda? Y N How often? __________________________________________________How much water do you drink per day? _________________Filtered? Y NPlease answer the following questions, be frank, no judgment here. Yes or No (Circle one)If you’re feeling down, does a snack make you feel better? YN When you miss a meal, do you get cranky until you get food? YNDo you have a hard time going to sleep without a bedtime snack? YNDo you get tired and/or hungry in the mid-afternoon? YNDo you get sleepy, almost “drugged” feeling after eating bread, pasta or dessert? YNDo you think that now and then you’re a secret eater? YNDo you experience cravings for sugar, breads, pasta and baked goods? YNDo you feel shaky if you do not eat on time or have a snack? Y NDo you often find yourself irritable or angry? Y N How many bowel movements do you have in a day? _________ Color? __________ Texture? ____________Do you have pain or burning with urination? Y NDo you have any fears or anxieties? Y N ______________________________________________Are you missing any internal organs? Y N Please list: ________________________________________Do you take antacids (for reflux or indigestion)? Y NDo you have any allergies? Y NWhat foods give you a tummy ache? _______________________________________________What foods make you sleepy? ______________________________________________Are your hands and feet cold a lot? Y NDo you have hair on the top of your toes? Y NHave you been on or are you on hormone replacement therapy? YESNOMen:Do you struggle with the physical needs of sex? Y NDo you have pain during urination? Y NDo you have blood in your stool or urine? Y NDo you have any prostrate issues you know about? Y N Explain______________________________________________________________________________________Women:How are your cycles? ______________________________________________________________________________Are you, or have you ever been on birth control? Y N Fertility Treatments? Y NIf yes, give details: ________________________________________________________________________________ Are you trying to get pregnant? Y NHave you ever had miscarriages or stillbirths? Y NDo you have any reproductive issues you are aware of? __________________________________________ ____________________________________________Lifestyle:Do you smoke? Y N How Much? ___________How Long? Do you drink alcohol? Y N What kind? ____________How much____________How Often_________Do you use recreational drugs? Y N What kind? _____________ How often____________________Have you ever in past or current have a dependency on drugs or alcohol? Y NHow often do you move (walk, run etc.)? __________________________________________________________Do you currently or have you played any sports? Y N list____________________________________Do you have physical hobbies? Y N (Walking, running, swimming etc.)List___________________________________________Stress: How do you deal with stress? ______________________________________________________________________ What is your main source of stress? _____________________________________________ Are there times in the day that you feel your best? _________________ your worst?_________________Are you happy in your life right now? Y NHave you experienced any trauma in your past? Y NCheck the ones that apply to you:Brittle nailsHypotensionCold hands and feetInability to concentrateCold intoleranceInfertilityConstipationIrritabilityDepressionMenstrual irregularitiesDifficulty SwallowingMuscle CrampsDry SkinMuscle WeaknessElevated CholesterolNervousnessHypertension (unknown cause)Poor MemoryEyelid swellingPuffy EyesFatigueSlower HeartbeatHair LossThroat PainHoarsnessMedication for anemiaChemotherapy or radiationEat soy products (directly or in processed foods)FatigueSweatingGoiterTremorHeat intoleranceWeaknessHyperactivityWeight loss (unexplained)HypertensionInsomnia (P, T)Menstrual disturbanceWake up frequently (P)NervousnessSpinal Disk Problems (P)PalpitationsSexual Dysfunction (P)Depression (severe sudden onset) (P)Sudden on set bi-polar (P)Cardiomyopathy (P)Wandering or spotty arrhythmia (P)Memory lossEmotional TantrumsJoint PainFlu symptomsRashesSwollen Lymph – for a long timeEye inflammation (red and sore) – not itchyExtreme fatigueHeart PalpatationsHepatitisBell’s PalsyErythema MigransRed earlobesNeck & Back PainTMJHave you received any of the following diagnosis from a medical doctor? Chronic FatigueMultiple Sclerosis (P)Crohn’sPolymyalgia RhemuticaFibromyalgiaPolymyositisPTSDPsoriatic ArthritisGrave’s DiseaseReiter’sHashimotosRheumatoid ArthritisJuvenile ArthritisSclerodermaLupusSjogrensUlcerative ColitisVasculitisCMVHerpesMonoLyme’s DiseaseOther:Have you had any of the following that you are aware of – or do you suspect issues with any of these?BrucellaMycoplasmCandidaNeisseriaChlamydiaParovirus B19CoxiellaStaphylococcus AureusFungiStreptococcusHepatitis BTreponema PallidumHIVOther Viruses: list belowMycobacterium TuberculosisHave you had any traumas such as:Whiplash or Motor Vehicle Accident (esp. with air bag deployment)? ____________Concussion or head injury? ___________Serious fall where your head or neck may have been injured, damaged or thrown around? ________Mild to moderate blow to the head? _______Sexual abuse as a child? -_________Radiation exposure? _________Huffing or snorting drugs? _______Prolonged high stress?? ________What diagnosis have you received in the past:________________________________________________________________________________________________________________________________________________________________________________________Health HistoryDo you presently, or in the past ever have any of the following conditions? (Circle those that apply)AnemiaFrequent Headaches Chronic cold/flu symptomsSkin ConditionsArthritisHeartburn Thyroid ConditionAsthmaChest Pains Diabetes DepressionChronic FatigueOsteoporosisLiver Problems HypoglycemiaKidney ProblemsHigh CholesterolHigh Blood PressureUnexplained Weight ChangesWhat was your childhood health and emotional experience like? ____________________________________________________Were you born c-section? YesNoDid you have antibiotics, anti-inflammatories, or immune suppressing medications? ______________________Have you ever had eczema, psoriasis or any other Skin conditions? _______________________________Surgeries, starting with most recent: __________________________________________________Hospitalizations:___________________________________________________________________________________________Hospitalizations:___________________________________________________________________________________________Hospitalizations:_________________________________________Circle any of the following that have applies to you within the last 90 days:NauseousBloatingHeartburnConstipation Belch after meals Gas DiarrheaBloated after meals abdominal/intestinal pain Travel outside US Gurgles in StomachAlternate constipation/diarrhea Stool compact/hard to pass Physical BodyIn your estimation, how physically fit are you right now? UnfitBelow AverageAverage Above Average Very FitHow often do you exercise? __________________________________________________If you do not exercise, what types of exercise have you enjoyed in the past?____________________________________Please list any parts of the body that hurt. Which one is the worst? __________________________________________How do you feel when you get up in morning? (Example, stiff)_______________________________________________How many hours of sleep do you get on average? ____________________ Do you get up in the night? Y NIf yes – what time approximately? __________ For what reason? _________________________Do your feet hurt a lot? Y NDo you have difficulty concentrating? Y N Do you feel fuzzy headed? Y NOf this list, what changes are you willing to make to improve or get rid of your symptoms? Diet/FoodHydration Exercise Healthy Supplements Client Signature:_____________________________________________________Date: _________________ ................
................

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

Google Online Preview   Download