New Client Form

Please fill out this form prior to your first session.

(We recommend filling out this form on a desktop computer.)

Health and Well Being History Form

Part 1

Please answer the following questions honestly and to the best of your ability









Have you ever had this problem before?


Part 2

Please mark what best describes the frequency with which you experience the below conditions.

Digestion

Loose stool or Diarrhea
Constipation
Poor digestion
Parasites
Acid reflux
Hiatal hernia
Nausea/vomiting
Gas or belching
Stomach or intestinal pain
Heartburn
Excessive appetite
Poor appetite
Irritable bowels
Hemorrhoids
Blood in stool
Black or dark stool
Light colored stool
Difficulty digesting oily food
High cholesterol
Gallstones

Respiratory

Wet cough
Dry cough
Chest tightness
Shortness of breath
Congestion
Wheezing
Nasal problems
Poor sense of smell
Sinus problems
Allergies
Hay fever
Catches colds easily
Other
Other
Pneumonia
Asthma
Emphysema
Bronchitis
Do you smoke?

Number per day
Cardiovascular

Hypertension
Hypotension
Chest pain
Dizziness
Easily bruised
Edema
Cold hands / feet
Restlessness
Heart palpitation
Slow heart rate
Poor circulation
Blood clots
Sweaty hands / feet
Anemia
Heart disease
Phlebitis
Poor blood clotting
Heart attack

How many times?

Stroke

How many times?

Other

Other
Urinary

Painful urination
Incontinence:
Difficulty with urination
Ringing in ears
Earaches
Hearing impairment
Kidney stones
Kidney infections
Low back pain
Knee problems
Other

Other
Nervous system

Dyslexia
Learning disorder
Multiple Sclerosis
Muscular dystrophy
Epilepsy
Head injury
Numbness

Where?

Tingling

Where?

Developmental or growth problems
Nervous disorder

Type
Muscles / joints

TMJ pain
Facial pain
Loss of balance
Poor coordination
Leg weakness
Arm weakness
Trunk weakness
Difficulty walking
Joint swelling
Osteoarthritis
Rheumatoid Arthritis
Artificial joints
Broken bones / fractures

Where?

Pins, etc

Where?

Mark painful areas of the body

Shoulder

Which one?

Arm

Which one?

Elbow

Which one?

Hands

Which one?

Hip

Which one?

Legs

Which one?

Knee

Which one?

Foot

Which one?

Neck

Which side?

Upper back

Which side?

Mid back

Which side?

Low back

Which side?

Limited movement

Where?
Other

Insomnia
Depression
Sleep too much

How long?

Shaky
Poor memory
Difficulty paying attention
Anxiety
Easily angered
Obsessive tendencies in work relationships
Difficulty making decisions
Dizziness
Soft or brittle nails
Intolerance to temperature / weather changes:
Fever
Chills
Nose bleeds
Swollen glands
Fatigue
Difficulty with speech
No thirst
Excessive thirst
Dry mouth
Pain at night
Headaches
Migraines
Eye pain
Dry eyes
Watery eyes
Other eye problems

Describe

Dental problems
Poor hearing
Difficulty swallowing
Diabetes
Weight gain
Weight loss
Tuberculosis
Thyroid problems
Fibromyalgia
Poor sense of smell
Poor sense of taste
Cancer

Where?

Allergies

List

Hepatitis

Type

Infectious disease

Describe

Herpes
Candida
Shingles
Chemical dependency

Describe

Skin condition

Describe
Select your sex

Male

Prostate problems
Pain associated with genitals
Impotence
Problems urinating
Infertility
Prostate cancer

Female

Breast pain or tenderness
Breast lumps
Nipple discharge
Menopause
Menopausal symptoms

Describe

Are your cycles regular?
Length of cycle
Painful menses with heavy or excessive flow
Painful intercourse
Ovarian cysts
Endometriosis
PMS
Infertility

Wellbeing

Please select any of the following feelings you have experienced in the last few months.



Please select what best describes the level of stress for the below listings.

My family stress is:
My relationship stress is:
My work stress is:
My financial stress is:
My health stress is:




Do you exercise?

How many hours a night do you sleep?
Is your sleep restful?

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