Client questionnaire

This form may take an hour to complete because it is very comprehensive. Completion of this form is required before a service can be scheduled. This form will help significantly reduce the amount of time typically used during a client-paid session to go over introductory information thereby saving the client money and allowing the client-paid sessions to work on more advanced issues. Please be as honest as possible and provide as much information as possible to ensure an accurate and productive assessment. You can skip any question that does not apply to you or a child (if you are a parent or guardian completing the form for a child). All information provided by client in this questionnaire, over the phone, or during any consultations or sessions will be kept strictly confidential.

8) Medical History (major health problems, accidents, injuries, and all surgeries/operations/abortions):

If answered Yes above, what do you wear? Eye Glasses Contact Lens Other:       Nothing

Reason for wearing them: Nearsighted Farsighted Presbyopia Astigmatism Cataracts Other:      
11) Amalgam Fillings? I have them in my teeth now. I had them in the past, but not now. I never had any.
Root Canals? Yes, I had them done in the past. No, I never had them done.

If answered Yes, how many have you had?      

Vaccination Type(s):  Standard childhood vaccines Annual flu shots Other:      

14) What and when do you normally eat and drink for:

15) Please list any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) including time of day or month:      

How often do you eat from other types of restaurants?      

Please list the restaurants you like to frequent here:      

If client is a child, does the child eat lunch provided by the school? Yes No

22) Check all the types of pots, pans, cookware, bakeware, rice cookers, crock pots (slow cookers), grills, coffee pots, tea kettles, etc. you use to cook your food. The materials below refer to the part of the cookware that comes in contact with food: Aluminum Iron Glazed ceramic, porcelain enamel, or clay Anodized aluminum Copper Unglazed clay Non-stick coating (Teflon or other) Glass Silicone Stainless steel Plastic Stone Other type:      

If answered Yes, approximately how long did you lived in these places in total?      

If Yes, how much per day?      

Do you get tired or sleepy during your usual waking hours? Yes No

Are you exposed to any source of light during sleep? Nightlight Street lights Alarm clock T.V. Other:      
31) How often and how long do you typically spend time outdoors?      
32) How often and how long do you typically expose your skin to direct sunlight without any sunscreen?      
33) If you are celibate, how long have you been celibate and what are your reasons for celibacy?      
34) If you are sexually active, how often do you engage in sexual activity with or without a partner?      
Which of the following contraceptives do you use? Oral contraceptives Rhythm-method I.U.D. Diaphragm Condoms Mucous-method Cervical Cap Spermicides Fertility lens None
35) If female, please provide the following pregnancy and menstruation history:

	How Many?	Year(s)	Complications
Pregnancies	     	     	     
Miscarriages	     	     	     
Abortions	     	     	     
First Period	N/A	     	     

36) Please use this space to add any other information that you think would be helpful in understanding your physical condition:      

Where were you born? In a Hospital Birthing Center At Home Other:      

 I am often not able to express my emotions.

 I express my emotions but often in a destructive way.

 I am often stressed out and feel overwhelmed.

 Even though I'm in a relationship, I often feel lonely.

 I often feel anxious and nervous for no good reason.

 I don't sleep well at night and have a hard time waking up in the morning.

 I often suffer from bad dreams and nightmares.

 There are many things I'd like to change in my life. I just don't have the time or means.

 I have very low energy and often feel exhausted mentally and physically.

 I don't enjoy my work and would rather be doing something else.

 I find my children irritating and hard to relate to.

 I have very few hobbies, interests, passions, dreams, or goals in life.

 I often feel depressed for no reason.

 I feel I have very little control over my life--that my life is not happening the way I want it to.

 I have a hard time letting go of the past.

 I don't look towards the future with much enthusiasm.

 I am not able to concentrate for extended periods of time.

 My outlook is more negative than positive.

 I spend a great deal of time worrying about what people think about me.

 I tend to see the good in people.

 I have a great sense of humor and love a good joke.

 I receive great joy from my family.

 My outlook on life is positive.

 My job uses all my greatest talent.

 I have plenty of energy to do all the things I want.

 I sleep well at night and feel rested in the morning.

 I can concentrate on the task at hand for as long as it takes.

 I have a strong spiritual trust in God, the Universe, and my Higher Self to support me and provide all that I need.

 I am able to express anger and other negative feelings constructively.

 I practice meditation or other relaxation techniques.

 I feel deep peace and tranquility.

 I have many close friends that I can always count on.

 I accept full responsibility for everything that happens to me in my life because I know that I created this life I am living.

 I trust my intuition because it is almost always accurate.

 I do not harbor any resentment from the past.

 I can feel completely fulfilled even if I'm alone.

 I have many hobbies, interests, passions, dreams, and goals in life.

 How I see myself is more important than how others see me.

2) Please use this space to add any other information about yourself that you think will be helpful:      

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Signature Date Signed

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