Health Assessment

This pre-consultation questionnaire asks you to assess how you have been feeling during the last 3 months. This information will help you keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to complete this questionnaire.

For each question, please select from the drop down menu the answer that best describes your symptoms:

No/Rarely - You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly or less)
Occasionally - Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
Often - Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it
Frequently - Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis

Let's begin by first reviewing your Medical History, then we will get to the assessment part, and finally your consultation booking.
Patient ID#
Date of Birth
Date of 1st Consult
Relationship Status
Body Type
Service Type