Name
*
First Name
Last Name
Gender & Pronouns
Marital Status
Married
Single
Divorced
Partnership
Widowed
Age
Height
Current Weight
Past Weight
Occupation
Address
*
Phone
(###)
###
####
Email
*
Please describe your present health concerns and their duration.
Are you under the care of a family physician or health professional?
Are you currently taking any medications or receiving treatment for your health condition?
If so, please list all medications/treatments and their dosage.
Do you have any allergies?
If so, please explain.
Do you have any past medical history?
If yes, please specify the age of occurrence, duration, and treatment.
How would you rate your health as a child?
Good
Fair
Poor
How would you rate your digestion?
Good
Fair
Poor
Do you experience any of the following digestive issues?
Please check all that apply.
Bowel Movements
Timing and frequency of your bowel movements. Please check all that apply
If other, please specify:
Are you bowel movements associated with any of the following?
Please check all that apply.
If other, please specify:
What best describes your bowel nature?
Soft
Medium
Hard
Do you have any of the following urinary problems?
Please check all that apply
If other, please specify:
Do you delay or suppress any of the following natural urges?
Please check all that apply.
What time do you usually go to sleep?
Hour
Minute
Second
AM
PM
What time do you usually wake up?
Hour
Minute
Second
AM
PM
Do you sleep during the day?
Yes
No
How do you generally feel when you wake up in the morning?
Fresh and rested
Little tired
Very tired
How would you describe your sleep?
Please check all that apply.
How would you rate your present emotional state?
Excellent
Good
Fair
Poor
Do you often experience any of the following?
Please check all that apply.
How would you rate your relationships with family members?
Excellent
Good
Fair
Poor
How would you rate your social life?
Excellent
Good
Fair
Poor
How would you rate your level of mental clarity?
Excellent
Good
Fair
Poor
How would you rate your career?
Love it
Like it
Dislike It
How purposeful is your life?
Completely
Neutral
Not happy
Rate your spiritual life:
Satisfying
Neutral
Empty
How regular is your daily routine?
Very regular
Somewhat regular
Irregular
Do you practice any type of meditation?
Please explain.
Do you practice any yoga techniques?
Please explain.
Do you travel a lot?
Yes
No
How often do you smoke cigarettes?
Never
Less than once a week
About once a week
Several times a week
More than once a day
How often do you consume alcohol?
Never
Less than once a week
About once a week
Several times a week
More than once a day
How often do you drink caffeinated beverages?
Never
One cup daily
2-3 cups daily
4+ cups daily
What type of weather makes you feel the most uncomfortable?
Cold
Cool and damp
Hot
What is your body build?
Thin
Average
Muscular
Large
Are you overweight?
Yes
No
How often do you exercise?
Once a week
Twice a week
3-4 times a week
5-6 times a week
Everyday
Not at all
About how long do you exercise for?
What type of exercise do you do?
Which of these best describes the intensity of your exercise?
Vigorous
Moderate
Light
What do you typically eat?
Please provide a list for each meal (breakfast, lunch, dinner, and snacks)
Do you snack between meals?
Yes
No
Do you eat your meals at the same time everyday?
Yes
No
What is your main meal?
Breakfast
Lunch
Dinner
How much water do you drink per day?
None
1-2 glasses
3-4 glasses
5-6 glasses
7 or more
Which of these options best describe your eating habits?
Please check all that apply.
Which of these options best describes your diet:
Vegan
Lacto-vegetarian
Ova-lacto-vegetarian
Other
What kinds of meats and animal-based proteins do you consume?
Please check all that apply.
If other, please specify:
What taste(s) do you like or crave?
Please check all that apply.
Are there any particular foods that cause discomfort when you eat them?
If other, please specify:
Which of the following best describes your menstruation?
Choose all that apply:
How many days does your menstrual period last?
0-4 days
5-7 days
7+ days
Spotty or irregular throughout the month
Other
If other, please explain:
How is your menstrual flow?
Heavy
Normal
Light
What symptoms do you associate with (before or during) your menstrual cycle?
Please check all that apply.
Do you experience pain during intercourse?
Yes
No
Do you have any sexual difficulties?
If yes, please explain.
Are you pregnant?
Yes
No
I don't know
Do you take contraceptive pills or use other forms of birth control?
If yes, please explain.
How many times have you been pregnant in the past?
How many children do you have?
Do you do breast self-exams regularly?
Yes
No
Do you experience any problems with your breasts?
Which of the following best describes your mental activity?
Quick, active, restless
Sharp, critical, aggressive
Calm, steady, slow, stable
Which of the following best describes your memory?
Good short-term
Generally good
Good long-term
Which of the following best describes your ability to concentrate?
Weak
Generally good
Very good
Which of the following best describes your ability to learn?
Quick to grasp things
Moderate ability to grasp things
Slow to grasp things
Which of the following best describes your dreams?
Fearful, very active, flying
Aggressive, fiery, adventurous
Which of the following best describes your sleep patterns?
Light, interrupted
Sound, medium
Sound, heavy, long
Which of the following best describes your speech?
Quick, can miss words
Sharp, direct, strong
Slower, clear, melodious
Which of the following best describes your voice?
High-pitched
Medium-pitched
Low-pitched
Which of the following best describes your eating speed?
Fast
Medium
Slow
Which of the following best describes your hunger level?
Irregular
Sharp, can be strong
Can easily miss meals
Which of the following best describes your food/drink preferences?
Warm
Cold
Dry and warm
Which of the following best describes your ability to set and reach goals?
Easily distracted
Focused and driven
Slow and steady
Which of the following best describes your level of giving?
Give small amounts
Give nothing or large amounts infrequently
Gives regularly and generously
Which of the following best describes your relationships?
Many casual
Intense
Long and deep
Which of the following best describes your sex drive?
Variable, low
Moderate
Strong
How do you work best?
Supervised
Alone
In groups
What kind of weather do you prefer?
Warm and moist
Cold and dry
Warm and dry
Which of the following best describes how you react to stress?
Excites quickly
Medium
Slow to get excited
Which of the following best describes your finances?
Doesn't save, spends quickly
Saves, but big spender
Saves regularly, accumulates wealth
Do you like routine?
Dislikes routine
Likes planning and organizing
Works well with routine
Which of the following best describes your mood?
Changes quickly
Changes slowly
Steady, unchanging
Which of the following best describes your reaction to stress?
Fear
Anger
Indifference
Would you say you are more sensitive to your own feelings or to others'?
Own feelings
Not sensitive
Others' feelings
How do you react when you feel threatened?
Run
Fight
Make peace
Which of the following best describes your relations with your spouse/partner?
Clingy
Jealous
Secure
How do you express affection?
Words
Gifts
Touch
How do you react when your feelings are hurt?
Cry
Argue
Withdraw
Which of the following best describes the way that you react to emotional traumas?
Anxiety
Denial
Depression
How confident are you?
Timid
Outwardly self-confident
Inner confidence
Which of the following best describes your hair?
Average
Thinning
Thick
Which of the following best describes your hair type?
Dry, frizzy, thin, dark
Straight, fine, premature graying
Oily, wavy, thick
Which of the following best describes your hair color?
Brownish
Auburn, reddish, blond
Dark brown, black
Which of the following best describes your skin?
Dry or rough, dark/sallow, tans easily, cold
Soft, light, sunburns easily, warm
Oily, moist, fair, thick, cool
Which of the following best describes your complexion?
Darker
Pink, red
Pale/white
Which of the following best describes your eyes?
Small, brown/gray/violet/unusual color
Medium, green/blue/hazel, almond-shaped
Large, dark brown or deep blue
Which of the following best describes the whites of your eyes?
blue/brown tint
yellow/red tint
bright glossy white
Which of the following best describes your gaze?
Nervous, darting
Sharp, piercing
Soft
Which of the following best describes your teeth?
Very large or very small
Small/medium
Medium/large
Which of the following best describes your weight?
Thin, hard to gain
Medium
Heavy, easy to gain
Which of the following best describes your stool?
Dry, hard, thin, easily constipated
Many during day, soft to normal
Heavy, slow, thick, regular
Which of the following best describes your level of sweating?
Scanty
Profuse
Moderate
