|
|
Confidential Holistic Health Survey - This survey should take about 15-20 minutes to complete. Be as thorough as possible. Please print copy of survey for yourself before submitting.
|
Name
|
Address
|
E-mail / How often do you check?
|
Primary phone / Alternate no. / Best time to call
|
Age / Height / Date of birth / Place of birth
|
Current weight -- weight six months ago -- 1 year ago
|
Children (ages) / number of grandchildren
|
Relationship status / How do you feel about your current relationship status?
|
Occupation / Number of hours worked per week
|
Do you enjoy your work / If not, what would you rather be doing?
|
What are your main health concerns?
|
Any serious illness/hospitalization/injuries?
|
How is the health of your mother if living? If not living, what was primary cause of death?
|
How is the health of your father if living? If not living, what was primary cause of death?
|
What is your ancestry?
|
What is your blood type? / What is your blood pressure?
|
Do you sleep well? / How many hours? / Do you wake up at night? If so, why?
|
Any pain, stiffness or swelling?
|
Periods regular? / Days of flow? / Menopausal? / Pain, symptoms or discomfort associated with menses or menopause?
|
Prostate concerns?
|
Reproductive concerns?
|
Constipation/Diarrhea/Gas? If yes, explain.
|
Do you take any supplements or medications? Please list.
|
Have you ever visited an alternative therapist in any of these fields: accupuncture, naturopathy, chiropractics, homeopathy, energy healing, other? If yes, what were you treated for and was it successful?
|
Are you currently active in any sports and exercise? If so, what and how often?
|
What are your hobbies or favorite leisure activities to engage in?
|
Do you currently have a need for any vision or dental work?
|
What types of food do you generally eat for breakfast, lunch, dinner, snacks and liquids? (Be real, and don't only list the good ones)
|
What are your favorite foods? Least favorite?
|
Do you have any allergic reations to foods?
|
How many servings of fruits & vegetables do you eat every day?
|
How much plain water do you drink daily? From what source?
|
What is/are the most difficult challenge(s) you are facing right now?
|
Do you feel confident you can handle them? If not, what support do you need?
|
Do you feel comfortable with your spirituality? Do you consider yourself to have a strong religious practice? Do you feel you have an intimate relationship with God?
|
What is the best way you want to feel physically, mentally, emotionally, spiritually? Use descriptive words.
|
How close are you to feeling this way?
|
What are you willing to do to reach your optimal health & wellness?
|
Do you feel you can work towards optimal goals on your own or do you need some type of support?
|
Where would you like to meet for your 1 hr. survey interview session?
At your home
On the phone
At a coffee shop or restaurant
At a park (weather permitting)
In an office environment
Other
It doesn't matter
|
If you chose other, where would you suggest?
|
Tentatively, what date is best for us to meet?
|
What time of day?
Hours
:
Minutes
|
|
|
