Questionnaire Page

Name:^*

Email^*

Date Of Birth:^*

*Please complete the form by choosing the right option as applied to you:

If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by choosing the right option as applicable to you: 1 for "mild or rarely occurring", 2 for "moderate or regularly occurring", 3 for "severe or often occurring", or "does not apply" if the symptoms/statements does not apply to you.

1. General fatigue or weakness

2. Difficulty losing weight

3. Frequent illness/infections

4. High stress lifestyle

5. Smoking

6. Drinking more than 2 cups of coffee/day

7. Bad breath and/or body odour

8. Constipation

9. Bags under eyes

10. Crave sugars, bread, alcohol

11. Difficulty digesting certain foods

12. Have used antibiotics in past 10 years

13. Allergies

14. Poor concentration and memory

15. belching or burping after meals

16. skin/ complexion problems

17. frequent consumption of red meat

18. regular use of diary products

19. Heavy alcohol consumption

20. exposure to toxins chemicals

21. frequent mood swings

22. depressed and/or irritable

23. brittle fingernails

24. Dry, brittle hair, split ends

25. high fat/ high cholesterol diet

26. nervousness/ anxiety/ tension/ worry

27. insomnia/ restless sleep

28. low fibre diet

29. muscle cramps

30. sleepy when sitting up

31. female: menstrual cramps

32. bronchitis/ asthma/ pneumonia/ emphysema

33. cellulite

34. cold hands and feet

35. varicose veins

36. feeling out of control

37. food/ chemicals sensitivities

38. frequent yeast/ fungus problems

39. bones break easily, osteoporosis

40. too little exercise

41. excessive mucous

42. short of breath climbing stairs

43. tingling in lips, fingers, arms, legs

44. chest pains

45. very rapid or slow heart beat

46. painful, hard or thin bowel movements

47. alternating constipation/ diarrhea

48. recurrent bladder infections

49. Female: menopause, hot flashes

50. Female: PMS

51. difficult urination

52. swollen glands, puffy throat

53. lower abdominal pain

54. frequent need to urinate

55. joint pain

56. sinus inflammation/ discharge

57. arthritis

58. sudden weight gain/ loss

59. headaches/ migraines

60. female: taking birth control pills

61. lower back pains

62. dry, flaky skin

63. drink less than 6 glasses of fluids/day

64. water retention

65. low sex drive

66. feeling heavy/bloated after meals

67. chronic cough

SCORES TOTAL:

lifestyle assessment e-form

name:^*

date:^*

Age:^*

* maleI'm a male

* femaleI'm a Female

height (In feet + Inches):

weight:

what is your purpose in coming here today?

what are your main health concerns/complaints? Please list in priority:

have you experienced any major trauma in the past 5 years?

what level of stress do you feel you are experiencing at this time? Please quantify on a scale of 1 (low) to 10 (high):

*what are the major causes or factors of your stress? rate all that apply on a scale of 1 (low) to 10 (high):

*financial

*career

*personal

*marriage

*health

*family

*spiritual

*unfulfilled expectations

*others (Please elaborate):

how does your stress manifest itself?

do you use any coping mechanisms?

what do you do for exercise? (indicate type, frequency, time of day and duration)

on a scale of 1 (low) to 10 (high), how would you describe your energy levels:

do you experience any lulls or highs in your energy levels throughout the day? if so, at what time of day?

how many hours on average do you sleep daily? (include naps)

What time do you go to sleep?

Awaken?

do you have trouble falling asleep?

staying asleep?

do you awaken feeling rested?

yes

no

do you snore?

yes

no

what is your occupation?

do you enjoy your work?

yes

no

sometimes

how many hours each day do you work?

at what times do you start and end work?

do you work shifts or are you on a regular schedule?

do you smoke?

Yes, i do smoke

no, I don't smoke

if "yes", how much and for how long?

if "no", does anyone in your household or workplace smoke?

yes

no

do you wish to gain weight?

yesno

lose weight?

how much?

by when do you wish to reach your goal weight?

what is your main motivation to change your weight?

how many hours do you spend daily, on average:

driving

watching television

reading

in front of computer

what are your interests and hobbies?

do you go on vacation regularly?

yes

no

when was your last vacation?

do you actively participate in any spiritual discipline (church, religious group, meditation, etc.)?

yes

no

medical history:

are you currently taking any medication?

yes

no

list all medications and the reason(s) for each:

do you take birth control pills?

have you taken antibiotics over the past 5 years?

yesno

please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosages:

do you have any allergies or sensitivities?

yesno

if so, please list:

do you have anaphylaxis (life-threatening allergy)? if so, please describe:

do you have any silver-mercury fillings?

yesno

have you ever been:

(a) diagnosed with an illness?

yesno

* if so, please explain:

(b) hospitalised

yesno

* If yes, for what reason?

have you had surgery to remove your gall bladder?

yesno

tonsils?

yesno

appendix?

yesno

how often do you have a bowel movement?

do you strain to have a bowel movement?

yesnooccasionally

related to particular food or circumstances?

do you have loose bowel movements?

yesnooccasionally

related to particular food or circumstances?

is there undigested food in your stool?

yesnooccasionally

do you use recreational drugs?

yesno

if yes, how often and what type?

have you ever been treated for drug?

and/or alcohol?

dependency?

family history:

hereditary diseases: use "f" for father, "m" for mother, "s" for siblings, "g" for grandparent, "o" for other(s):

1. allergies

diabetes

intestinal disease

alcoholism

drug abuse

kidney dysfunction

athritis

gall bladder issues

mental illness

asthma

heart disease

osteoporosis

autoimmune disease

hypertension

skin conditions

cancer

type:

ulcers

* other diseases (please list)

have you experienced fungal infections (e.g, jock itch, athlete's foot)?

yesno

* if yes, please describe:

have you experienced a decline in sexual interest?

yesno

* if yes, please describe:

have you had kidney or gall stones?

yesno

* if yes, please describe:

females:

are you or could you be pregnant?

yesno

have you noticed any changes in menses, for example the frequency, duration, flow, clotting, or other changes?

yesno

* if so, please specify:

do you suffer from PMS symptoms? please specify:

are you peri-menopausal?

yesno

menopausal?

yesno

are you experiencing any menopausal symptoms?

yesno

* if yes, please specify:

have you had a bone density test?

yesno

* if yes, what was the result?

males:

have you experienced any prostate problems (e.g, frequent urination, discomfort during urination)?

yesno

* if yes, please describe:

dietary habits:

how many times a day do you eat:

*main meals:

times of day:

*snacks:

times of day:

do you eat meals:

with family

home alone

on the run

restaurant

fast food

do you feel there are restrictions to your diet due to preferences of others such as family, roommates, etc?

yesno

* if yes, please explain:

how many 1/2 cup servings of each do you typically eat in a day:

* fruits:

* fresh:

* dried:

* canned:

* vegetables:

* cooked:

* raw:

* whole grains:

* protein:

type:

* diary products:

type:

* other:

specify:

provide examples of your typical meals:

*breakfast:

*lunch:

*dinner:

*snacks:

do you eat or use (indicate "1" for "rarely", "2" for "regularly", "3" for "often")

*aluminum pans

*margarine

*candy

*microwave

*fried foods

*fast foods

*luncheon meats

*cigarettes

*artificial sweateners (nutra sweet, aspartame, splenda)

*refined foods (pastries, white bread/pasta/rice, etc)

please indicate how many cups of the following you drink per day:

*tap water

*prepared vegetable juices

*coffee

*fresh vegetable juices

*tea

*red wine

*soft drinks (diet)

*white wine

*soft drinks (regular)

*beer

*fresh fruit juices

*other alcoholic beverages

*fruit juices (prepared)

*bottled or spring water

*milk (1%, 2%, or whole)

*herbal tea

*milk (skim)

*other

are you a:

meat eater?vegetarian?vegan?

how often do you eat meat?

daily3-5/weekonce/week or less

how often do you consume dairy products?

daily3-5/weekonce/week or less

what are your favourite foods?

how often do you eat them?

which food(s) do you crave, and how often do you eat them?

do you avoid certain foods?

yesno

* if so, why?

do you experience any symptoms if meals are missed? explain:

do you experience any symptoms after meals? explain:

comments:

client statement:

i understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. this statement is being signed voluntarily.

date:

signature:

name:

address:

city:

prov:

postal code:

phone: (H)

(w)

(c)

you are on your way to wellness!

NSP CLIENT ASSESSMENT FORM

lifestyle assessment e-form

medical history:

family history:

females:

males:

dietary habits:

client statement: