me me family me me family me me family past current members past current members past current members Allergies Fibromyalgia Anemia High Blood Asthma ADHD Pressure Irritable Bowel Eczema Syndrome Disease Migraine Osteoporosis Cancer Diabetes High Cholesterol Arthritis Learning Heart Stroke Disability Disease Sexual Eating Thyroid Disease Problems Disorder Anxiety Depression Phobias Bipolar Panic Attacks Suicidal Borderline Obsessive/ Personality Compulsive Disorder (OCD) Other conditions not listed above: Approx. date of last physical exam: Approx. date of last bloodwork: Areas that were of concern at your last exam: Did your practitioner recommend any treatments? Yes No If yes, describe and explain whether you have implemented recommendations: Current prescription medications: Current supplements taken: Digestion and Nutrition yes no yes no Constipation Diarrhea Frequency of bowel movements per day: Diarrhea Nausea Consistency: Acid Reflux Bloating Describe food allergies or sensitivities: Dietary choices/restrictions (e.g., Vegan, Gluten-Free, Dairy-Free)? Yes No If yes, describe: Do you experience cravings? Yes No If yes, describe: Typical breakfast: Typical lunch: Typical dinner: Typical snacks: Lifestyle Screen Time
me past me current family members me past me current family members me past me current family members Allergies Fibromyalgia Anemia Asthma High Blood Pressure ADHD Eczema Irritable Bowel Syndrome Disease Migraine Osteoporosis Cancer Diabetes High Cholesterol Arthritis Stroke Learning Disability Heart Disease Sexual Problems Thyroid Disease Eating Disorder Anxiety Depression Phobias Bipolar Panic Attacks Suicidal Borderline Personality Disorder Obsessive/ Compulsive (OCD) Other conditions not listed above: Approx. date of last physical exam: Approx. date of last bloodwork: Areas that were of concern at your last exam: Did your practitioner recommend any treatments? Yes No If yes, describe and explain whether you have implemented recommendations: Current prescription medications: Current supplements taken: Digestion and Nutrition yes no yes no Constipation Diarrhea Frequency of bowel movements per day: Diarrhea Nausea Consistency: Acid Reflux Bloating Describe food allergies or sensitivities: Dietary choices/restrictions (e.g., Vegan, Gluten-Free, Dairy-Free)? Yes No If yes, describe: Do you experience cravings? Yes No If yes, describe: Typical breakfast: Typical lunch: Typical dinner: Typical snacks: Lifestyle Screen Time
0.-New-client-questionnaire-Fillable.docx