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New Client Intake
Administrator
2018-06-11T13:30:06+01:00
Health Assessment Form
New Client Intake
Page 1
Section 7
Female Only
Male Only
Health Complaints
Family History
Food Diary
sleep
Mould Screening
History
0% Complete
1 of 10
Name
*
First
Last
*
Last
Email
*
Phone number
Address
Date of birth
*
Age
*
Gender
*
Occupation
Blood Pressure
Pulse
Blood Type
Group 1
arrowup6
please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:
Acid foods upset
1
2
3
Acid foods upset
1
2
3
Frequently get chilled
1
2
3
Lump in throat
1
2
3
Dry mouth-eyes-nose
1
2
3
Pulse speeds up after meals
1
2
3
Feeling keyed up/difficulty calming
1
2
3
Cuts heal slowly
1
2
3
Gag easily
1
2
3
Unable to relax/easily startled
1
2
3
Extremities cold/clammy
1
2
3
Irritated by strong light
1
2
3
Reduced amount of urine
1
2
3
Heart pounds after retiring to bed
1
2
3
Nervous stomach
1
2
3
Frequent cold sweats
1
2
3
Fever easily raised
1
2
3
Neuralgia-like pains
1
2
3
Staring with infrequent blinking
1
2
3
Group 1 Total Score
Group 2
arrowup6
please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:
Joint stiffness on rising
1
2
3
Muscle/leg/toe cramps at night
1
2
3
Butterfly stomach
1
2
3
Watery eyes or nose
1
2
3
Frequent blinking
1
2
3
Swollen/puffy eyelids
1
2
3
Indigestion soon after meals
1
2
3
Always seem hungry; frequently lightheaded
1
2
3
Rapid digestion
1
2
3
Frequent vomiting
1
2
3
Frequent hoarseness
1
2
3
Irregular breathing
1
2
3
Slow pulse/irregular
1
2
3
Slow gagging reflex
1
2
3
Difficulty swallowing
1
2
3
Alternating constipation and diarrhoea
1
2
3
Slow starter
1
2
3
Frequently chilled
1
2
3
Perspire easily
1
2
3
Poor circulation, sensitivity to cold
1
2
3
Subject to colds, asthma, bronchitis
1
2
3
Group 2 Total Score
Group 3
arrowup6
please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:
Eating when nervous
1
2
3
Excessive appetite
1
2
3
Hungry between meals
1
2
3
Irritable before meals
1
2
3
Get shaky when hungry
1
2
3
Fatigue which is relieved by eating
1
2
3
Lightheaded if meals are delayed
1
2
3
Heart palpitations if a meal is missed or delayed
1
2
3
Afternoon headaches
1
2
3
Overeating sweets upsets
1
2
3
Waking after a few hours sleep - difficulty getting back to sleep
1
2
3
Craving for something sweet or coffee in the afternoon
1
2
3
Moods of depression, blues or melancholy
1
2
3
Abnormal craving for sweets or snacks
1
2
3
Group 3 Total Score
Group 4
arrowup6
please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:
Hands and feet go numb readily
1
2
3
Frequently sighing, feeling 'air hungry'
1
2
3
Aware of breathing heavily
1
2
3
High altitude discomfort
1
2
3
Needing to open windows in a closed room
1
2
3
Susceptible to colds & fevers
1
2
3
Afternoon yawner
1
2
3
Frequently feeling drowsy
1
2
3
Swollen ankles, worse at night
1
2
3
Muscle cramps, worse during exercise; get charley horses
1
2
3
Shortness of breath on exertion
1
2
3
Dull pain in chest or radiating into left arm, worse on exertion
1
2
3
Bruise easily, black/blue spots
1
2
3
Tendency to anaemia
1
2
3
Frequent nose bleeds
1
2
3
Noises in head or ringing in ears
1
2
3
Tension under breastbone or feeling of tightness, worse on exertion
1
2
3
Group 4 Total Score
Group 5
arrowup6
please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:
Dizziness
1
2
3
Dry skin
1
2
3
Burning feet
1
2
3
Blurred vision
1
2
3
Itchy skin and feet
1
2
3
Excessive hair loss
1
2
3
Frequent skin rashes
1
2
3
Bitter or metallic taste in mouth in the mornings
1
2
3
Bowel movements painful or difficult
1
2
3
Worrier, feeling insecure
1
2
3
Feeling queasy; headache over the eyes
1
2
3
Greasy foods upset
1
2
3
Light-coloured stools
1
2
3
Peeling skin on soles of feet
1
2
3
Pain between the shoulder blades
1
2
3
Frequent use of laxatives
1
2
3
Stools alternating from soft to watery
1
2
3
History of gallbladder attacks or gallstones
1
2
3
Sneezing attacks
1
2
3
Bad dreams, nightmares
1
2
3
Bad breath (halitosis)
1
2
3
Consumption of milk products causes distress
1
2
3
Sensitivity to hot weather
1
2
3
Burning or itching anus
1
2
3
Craving for sweets
1
2
3
Group 5 Total Score
Group 6
arrowup6
please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:
Loss of taste for meat
1
2
3
Lower bowel gas several hours after eating
1
2
3
Burning stomach sensations relieved by eating
1
2
3
Coated tongue
1
2
3
Passing large amounts of foul smelling gas
1
2
3
Indigestion half to one hour after eating (may be up to 3 or 4 hours)
1
2
3
Mucus colitis or Irritable bowel
1
2
3
Gas shortly after eating
1
2
3
Bloated stomach after eating
1
2
3
Group 6 Total Score
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