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The East-West Alchemist - New Client Health Questionnaire

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Please create and enter a unique 8-12 character long ID code. This is used instead of a name to ensure that your medical information is anonymous and protected. Make sure to write it down so you can relay it to me later.

[Just like any password, it can be letters and/or numbers, like "cycle982" for example. Be sure to make it unique, so avoid generic phrases like '12345678' or 'Volkswagen'.]

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What are your top 3 health concerns, in order of importance?

Please list any medical conditions that were not on the previous list:

SKIP if you do not have any more conditions to list

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On average, how would you rate your stress level on a scale of 1 to 10?

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On average, how would you rate your energy level on a scale of 1 to 10?

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On average, how would you rate your focus & memory on a scale of 1 to 10?

How many hours per night do you typically sleep?

What are your stress relief and mental wellbeing practices?

[This can be anything, from meditation, to yoga, to church, to connecting with family, to walking in nature. Skip this question if you're not sure if you have any.]

Do you subscribe to any particular kind of diet?

Please list any foods you are allergic to or believe you are sensitive to:

[SKIP if none]

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What did you last eat for breakfast?

[If you don't eat breakfast, write "I don't eat breakfast"]

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What did you last eat for lunch?

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What did you last eat for dinner?

List 5 of your favorite snacks

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How many ounces of water do you drink per day?

[Not counting coffee, tea, juice, soda, etc]

How much soda do you drink per day?

[This does not include sparkling water, just soda]

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Please list all the medications you take, including doses

[Do your best to fill this out completely but note if the list in not complete. Write "NONE" if you do not take any medications.]

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Please list all of the supplements you regularly take [at least 1-2 times per week]

[PLEASE INCLUDE manufacturer name and product name. Do your best to fill this out completely but note if the list in not complete. Write "NONE" if you do not take any supplements.]

Please list any major surgeries you have had

[SKIP if you have not had any.]

Please list any abnormal lab findings you have had in the last year

[If you can't find them right now, that's not a problem. Try to have them handy during your session if possible. SKIP if you have not had any abnormal labs.]

Do you feel any of these emotions on a very regular basis?

[Mark all that apply. SKIP if none of these apply or write the emotion in 'other'.]

Do you have adverse reactions to any of the following items?

[Mark all that apply or SKIP if none apply.]

Have you recently lived in a house with mold?

In order to improve your health, how ready are you to do these things on a scale of 1 to 3?

[1 = not willing at all and 3 = very willing]
1
2
3
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Modify your diet
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Modify your lifestyle
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Practice stress reduction techniques
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Take additional nutritional supplements
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Exercise