Holistic Choices

True Health Mastery - The Science and Ancient Art

CONFIDENTIAL COMPREHENSIVE QUESTIONNAIRE

Medical History
Are you presently on medication? (It is necessary to know this to determine any contraindications such as drug/nutrient interactions.)
Are you going to undergo surgery in the near future? If yes, please explain briefly.
Are you currently recovering from an injury? If yes, please describe briefly.
Are you presently recovering from any surgery or illness?
Don’t know your blood pressure?
Don't know your cholesterol reading?
Don't Know Your Liver Enzyme Count?
Don't know your serum protein levels?
I can email a copy of my recent laboratory test values to you.
Please list any reaction to foods that you are aware of, and describe how you are affected.
Please describe any chewing, swallowing, stomach or digestive tract problems you may be having.
What are your expectations in seeking our services?
PRELIMINARY DIETARY ANALYSIS FOR ENERGY EVALUATION
Are you presently taking any vitamin/mineral or other food supplements?
Do you presently take any medicinal herbs in capsule form, fresh, or dried? If so, please list them and the dosages:
Who recommended them?
Feel free to disclose things you feel are affecting your physical health. Psychological stress affects the body’s delicate chemistry. The kind of stress you have in your life, traumatic experiences, relationship issues--anything affecting your happiness, the better I am able to assist you with your health goals. The more I know about the factors that have affected your total health, the more information I have to help you succeed, so that we may work together to find realistic solutions. Some of these solutions might include use of other holistic health disciplines, if you feel you need to add another dimension to your wellness. The integrative use of different health modalities for the body, mind, and spirit helps you attain lasting, excellent health, and a quality life that you deserve. With an excellent referral network of dedicated holistic health practitioners, and with complete and correct nutrition at its core foundation, we can form a unique healthcare team to empower you with the knowledge required to always manage your wellness effectively.
Check the appropriate response, and "sign" electronically, and date below.
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Thank you! Your information has been submitted successfully. The nutritionist will contact you at the date and time you specified to discuss your health profile and set your appointment date and time. We look forward to serving your wellness needs.