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(Print and fill in this form and bring it to your consultation, also attach a recent photograph of yourself)

 

NAME

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DATE

D.O.B:
(compulsory)

 

TEL

MOBILE
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E-MAIL

OCCUPATION:

 

ADDRESS

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MARITAL STATUS

__

 

HEIGHT

_(compulsory)

 

WEIGHT

(compulsory)

 

SEX

(compulsory)

 

MEDICAL HISTORY/ MEDICAL TEST REPORTS / X-RAY ETC

 

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MEDICATION/SUPPLEMENTS, PRESENT:

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Client Information Form

The following questions will greatly assist in our being able to correctly identify your imbalances. Please circle the option that best describes you.

 

1. Bowel Movements

 

Do you move your bowels daily?YesNo

 

Is your bowel movement roughly at the same time of day?Yes No

 

When?Morning AfternoonEvening

Would you say you are constipated?Yes No

Do you have DiarrheaYesNo

Do your stools:floatsink

Have you observed the color?

Could you describe the odor?

2. Appetite

How many meals do you have daily123 4

Which is your main meal?

When do you get hungry?

Do you eat most meals at: home out

What are your favorite foods?

What time do you eat your last meal (usually)?

3.Sleep

How many hours sleep do you get a night?

Do you dreamhave nightmares

How would you say you sleep?

…………………………………………………………………………………..

Do you wake in the night to go to the toilet?YesNo

Do you wake up feeling -freshtiredstill sleepy

What time do you go to sleep?

4.Periods/ reproductive information

Is your monthly period regular? Yes No

Do you suffer any P.M.S? ……………………………………………………………..

If so briefly state how this affects you… …………………………………………….

Are you sexually activeYesNo

5. Exercise

What kind of exercise or games do you participate in?

………………………………………………………………………………………

How often do you exercise

………………………………………………………………………………………

 

6. Emotional state

What words would you use to describe your current state of mind?

What words would you use to describe your emotions?

7. Fluid intake

How many glasses of water do you drink in the day?

Do you wake in the night to drink water?YesNo

 

8. Physical Pains

Are you suffering form aches or pains in any part of your anatomy? If so state where

9. Nature of work

How active are in your job? Describe briefly if you interact with others if you sit or are on the move all day etc…

10. Travel

Do you have to travel as part of your workYesNo Often

Do you travel a lot for holidays YesNo