Assessment

Health Questionnaire:

First Name
Surname
Email
Phone
ID Number
Date of Birth
Gender
Location
Children
Date of 1st Consult
Relationship Status
Body Type
Weight
Height
ServiceType
Please list in order of importance:

Health matters to be addressed: 
1.
2.
3.
4.
5.

Please list in order of importance:

Medications and reason for use:
1.
2.
3.
4.
5.

Any major operations or injuries?

Any major illnesses or diseases in your family?

Please list below:
Mother:      (M)Grandparents:     Brothers/Sisters:    

 Father:       (P) Grandparents:     Other:

Daily Habits:

Item (Past or Present)  No Yes  
Smoker    

Years:    Type:    

Amount per day  

Alcohol Use     Type:     Drinks p/week:  
Coffee     Cups Per Day:     Type:      Milk?       Sugar ~ how many?  
Tea     Cups Per Day:      Type:      Milk?       Sugar ~ how many?  
Fizzy /Cool drinks     Cups Per Day:      Or Liters per week?      Type:  

Scale: 1 = very low; 5 = moderate; 10 = very high

Energy levels (1-10):      Stress levels (1-10):

Condition of Sleep:

What time do you go to bed and get up again?      How well do you sleep?

Bathroom pattern?

Bowel movements per day?

What change in your health would you most like to see?

Date:

Health Analysis Graph

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  • Gastrointestinal
  • Liver/GB
  • Endocrine
  • Glucose-Regulation
  • Cardiovascular
  • Mood
  • Immune
  • Urological
  • Musculoskeletal
  • CNS&Brain
  • Men
  • Women