CONFIDENTIAL COMPREHENSIVE QUESTIONNAIRE
Last Name, First, Middle Initial
Address, City, State, Zip
Area Code, Telephone
Email
FAX
Other Contact Information
Date of Birth
Gender (Male, Female?)
Height, Weight
Please indicate below how you feel on a day-to-day basis. Describe what problem or affliction you are experiencing.
Medical History
Are you presently on medication? (It is necessary to know this to determine any contraindications such as drug/nutrient interactions.) Yes
No
If yes, please indicate what medication/s you are on. Essential: Please be sure the spelling of your medications is correct.
Are you going to undergo surgery in the near future? If yes, please explain briefly. Yes
No
Are you currently recovering from an injury? If yes, please describe briefly. Yes
No
Are you presently recovering from any surgery or illness? Yes
No
If yes, please explain. (This is an important consideration through the healing process, for your total holistic health assessment, and learning experience.)
Please indicate your most recent blood pressure measurement: Systolic Diastolic
Don’t know your blood pressure?Don't Know
Blood Cholesterol: HDL LDL Overall mg/dl
Don't know your cholesterol reading?Don't Know
Liver Enzymes
Don't Know Your Liver Enzyme Count?Don't Know
Serum Protein
Don't know your serum protein levels?Don't Know
I can email a copy of my recent laboratory test values to you.Yes
No
It is important for us to know your laboratory values so we can monitor your progress as you build your health. It is recommended that you obtain this information from your physician for your own knowledge and records.
List any chronic illnesses, disorders, or diseases you currently have or have had in the past. This information will be taken under consideration in your overall holistic health assessment.
FOOD ALLERGIES
Please list any reaction to foods that you are aware of, and describe how you are affected.
DIGESTION
Please describe any chewing, swallowing, stomach or digestive tract problems you may be having.
GOALS AND EXPECTATIONS
What are your expectations in seeking our services?
PRELIMINARY DIETARY ANALYSIS FOR ENERGY EVALUATION
Are you presently taking any vitamin/mineral or other food supplements?Yes
No
If so, what brands, specific nutrients?
List any other supplements you are taking daily, and if possible, list the dosages.
HERBS
Do you presently take any medicinal herbs in capsule form, fresh, or dried? If so, please list them and the dosages:
Reason/s for taking them:
Who recommended them?Books, magazines, or brochure.
A health food store employee.
A friend or relative.
A medical doctor.
A natural health or holistic practitioner.
A different health professional.
Other
ADDITIONAL PERSONAL DATA (optional)
Feel free to disclose things you feel are affecting your physical health. Psychological stress affects the body’s delicate chemistry. The kind of stress you have in your life, traumatic experiences, relationship issues--anything affecting your happiness, the better I am able to assist you with your health goals. The more I know about the factors that have affected your total health, the more information I have to help you succeed, so that we may work together to find realistic solutions. Some of these solutions might include use of other holistic health disciplines, if you feel you need to add another dimension to your wellness. The integrative use of different health modalities for the body, mind, and spirit helps you attain lasting, excellent health, and a quality life that you deserve. With an excellent referral network of dedicated holistic health practitioners, and with complete and correct nutrition at its core foundation, we can form a unique healthcare team to empower you with the knowledge required to always manage your wellness effectively.
Holistic Choices works cooperatively as a professional courtesy with the medical community in the spirit of integrative health and cooperation of all health disciplines to provide you with the best possible, informed health options. Holistic Choices’ professional status is that of teacher of healthful living and not that of medical doctor. It is advocated that you involve your physician while implementing any alternative or wellness program to use precaution and be made aware of any contraindications; however it is your Constitutional right to decline this recommendation. If you choose to decline to inform your physician, it is essential you provide accurate information about your medications and your current dietary habits to the nutritionist. This prevents possible problems such as adverse drug-nutrient interactions that can affect the drug’s performance or hazardously increase its actions. Some drugs can block nutrient absorption while some nutrients can affect a drug’s desired effect.
Check the appropriate response, and "sign" electronically, and date below.Please notify my physician.
Please do not notify my physician.
I have sought the services of Holistic Choices, Mary Esther Gilbert, Holistic Nutritionist. I hereby certify that all of the information I have completed on this form is, to the best of my knowledge, true and correct. Client signature (parent or guardian if under 18 years of age)
Today's Date
We need to discuss the health profile you just provided, and set an appointment date and time for your consultation with the nutritionist. Please provide the best dates and times you can be reached.
Please provide the best telephone number at which to reach you, including area code.
Please select the best date to reach you.
Please select the best time to reach you.Hours01
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