Client Forms — Carmen Stanley Wellness

*For current clients (Please write N/A if new)

how long have we been working together?

*For current clients only (Please write N/A if new)

Are you receiving good support from those around you for the changes you are marking? Please describe.

Age

Height

Current weight

Place of birth

Weight 6 months ago

Weight one year ago

Would you like your weight to be different?

If Yes- why? If No- write N/A

*For current clients (Please write N/A if new)

What positive changes have you noticed since your last appointment? And what are your current concerns?

Relationship status

Do you have children?

Occupation

Hours you work per week

Please list your main health concerns

When was the last time you felt vibrant and well?

Other current major life concerns

If you could wave a magic wand and change 2 things about your life right now, what would they be?

Any serious illness, hospitalization, injuries and/or surgeries either now or in the past?

How is the health of your mother? If deceased, relay illnesses.

How is the health of your father? If deceased, relay illnesses.

What is your ancestry?

What blood type are you?

Do you sleep well?

How many hours?

Do you wake up at night?

Please explain your sleeping habits/patterns/why you wake at night

Any ongoing sources of inflammation (eczema or other skin issues, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?

Are your periods regular? Write N/A if this does not apply to you

How many days is your flow? Write N/A if this does not apply to you

How frequent? Write N/A if this does not apply to you

Painful or symptomatic? Write N/A if this does not apply to you

Please explain or write N/A if this does not apply to you

Birth control history

Any vaginal infections or reproductive concerns?

Do you struggle with constipation, diarrhea, gas, distension, belching, or bloating?

If Yes, which one and please explain. If No, please write N/A

*Current clients only (Please write N/A if new)

Are you taking all the supplements consistently? Any concerns? Please describe.

Please list all supplements and/or medications you take (prescription or over-the-counter) and what is the frequency?

Have you ever taken antibiotics more than a short course or two as a child? If so, when/how often? For what and for how long? If this does not apply to you please write N/A

Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?

What is the general status of your dental health/care?

Any troubling dental work or history of dental/oral infections? Dentures? Root Canals?

How many silver/mercury fillings do you have? Other major dental work/issues beyond basic cleanings?

On a scale of 1-10, how would you rate your general energy level? 1=lowest / 10= highest

To what do you attribute this energy level? Please explain

Any healers, helpers, pets or therapies with which you are involved? Please list:

What are your primary hobbies?

What role do sports and exercise play in your life?

What do you do to relax and how often?

What was your general health and well-being as a child?

*Current clients only (Please put N/A if new)

Are you cooking more? What are you craving and what are you doing or feeling when you're craving this?

What foods did you eat often as a child?

What do you often eat the most for breakfast?

What do you most often eat for lunch?

What do you most often eat for dinner?

What are your go to snacks?

What do you most commonly drink for liquids?

Please list any and all food allergies/sensitivities

What percentage of your food is home-cooked?

If you're not eating all of your food prepared at home where are you eating at?

If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly.

Do you crave sugar, carbs, alcohol, coffee, cigarettes, other foods, or have any addictions?

Anything else you would like to share?

SYMPTOM QUESTIONNAIRE

Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. If multiple choices are given, please specify what applies in the comment section. Leave the score blank if you NEVER have the symptom Use a 1 if you OCCASIONALLY have it and the effect is MILD Use a 2 if you OCCASTIONALLY have it and the effect is SEVERE Use a 3 if you FREQUENTLY or CONSISTENTLY have it and the effect is MILD Use a 4 if you FREQUENTLY or CONSISTENTLY have it and the effect if SEVERE

HEAD

HEADACHES

HEAD

FAINTNESS

HEAD

DIZZINESS

HEAD

INSOMNIA

NOSE

STUFFY NOSE

NOSE

SINUS PROBLEMS

NOSE

HAY FEVER

NOSE

SNEEZING ATTACKS

NOSE

EXCESSIVE MUCUS FORMATION

MOUTH

CHRONIC COUGHING

MOUTH

GAGGING OR FREQUENT NEED TO CLEAR THROAT

MOUTH

SORE THROAT, HOARSENESS, OR LOSS OF VOICE

MOUTH

SWOLLEN OR DISCOLORED TONGUE, GUMS, OR LIPS

MOUTH

CHRONIC TOOTH PAIN, GUM PAIN OR JAW PAIN? PLEASE ALSO LIST WHICH AND IF YOU GET FREQUENT CANKER SORES

SKIN

ACNE

SKIN

HIVES OR OTHER ALLERGIC BREAKOUTS

SKIN

RASH OR PERSISTENTLY DRY SKIN

SKIN

HAIR LOSS

SKIN

FLUSHING OR HOT FLASHES

SKIN

FREQUENTLY FEEL COLD

SKIN

EXCESSIVE SWEATING

SKIN

ANY PARTS OF YOUR BODY FREQUENTLY FEELS NUMB?

HEART

IRREGULAR OR SKIPPED HEARTBEAT

HEART

RAPID OR POUNDING HEARTBEAT

HEART

CHEST PAIN

LUNGS

CHEST CONGESTION

LUNGS

ASTHMA, BRONCHITIS

LUNGS

SHORTNESS OF BREATH

LUNGS

DIFFICULTY BREATHING

DIGESTION

NAUSEA OR VOMITING

DIGESTION

DIARRHEA

DIGESTION

CONSTIPATION

DIGESTION

BLOATED FEELING

DIGESTION

BELCHING, BURPING

DIGESTION

PASSING GAS, FLATULENCE

DIGESTION

HEARTBURN

DIGESTION

INTESTINAL OR STOMACH PAIN. WHICH?

DIGESTION

OTHER PAIN IN GI TRACT? IF SO, WHERE?

JOINTS AND MUSCLES

PAIN OR ACHES IN JOINTS

JOINTS AND MUSCLES

ARTHRITIS

JOINTS AND MUSCLES

STIFFNESS OR LIMITATION OF MOVEMENT

JOINTS AND MUSCLES

PAIN OR ACHES IN MUSCLES

JOINTS AND MUSCLES

TREMOR OR RESTLESS LEG

JOINTS AND MUSCLES

FEELING OF WEAKNESS OR TIREDNESS

WEIGHT

BINGE EATING/DRINKING

WEIGHT

CRAVING CERTIN FOODS

WEIGHT

EXCESSIVE WEIGHT

WEIGHT

COMPULSIVE EATING

WEIGHT

WATER RETENTION

WEIGHT

UNDERWEIGHT

ENERGY

FATIGUE, SLUGGISHNESS

ENERGY

APATHY, LETHARGY

ENERGY

HYPERACTIVITY

ENERGY

RESTLESSNESS

MIND

POOR MEMORY

MIND

CONFUSION, POOR COMPREHENSION

MIND

POOR CONCENTRATION OR FOCUS

MIND

POOR PHYSICAL COORDINATION

MIND

DIFFICULTY IN MAKING DECISIONS

MIND

STUTTERING OR STAMMERING

MIND

LEARNING DISABILITIES (PLEASE LIST)

MOOD

MOOD SWINGS

MOOD

ANXIETY, FEAR, NERVOUSNESS

MOOD

ANGER, IRRITABILITY, AGGRESSIVENESS

MOOD

DEPRESSION

MOOD

OTHER MOOD CHALLENGES?

OTHER

FREQUENT ILLNESS

OTHER

FREQUENT OR URGENT URINATION

OTHER

INABILITY TO URINATE OR LOW URINE FLOW

OTHER

LOW LIBIDO OR OTHER SEXUAL DYSFUNCTION

OTHER

GENITAL ITCH OR DISCHARGE

OTHER

WOMEN: BREAST FIBROIDS (N/A IF DOESN'T APPLY TO YOU)

OTHER

WOMEN: PAINFUL OR TENDER BREASTS (N/A IF DOESN'T APPLY TO YOU)

OTHER

WOMEN: PAINFUL OR TENDER BREASTS

OTHER

WOMEN: UTERINE FIBROIDS

OTHER

OTHER INFORMATION TO NOTE

PLEASE TALLY YOUR SCORE

WRITE THE TOTAL HERE

*Current clients only (Please write N/A if new)

Do you have any particular questions or topics you would like to cover in our next session?

*Current clients only (Please put N/A if new)

What do you see as a significant barrier to you making more/faster progress toward your health goals?

Confidential Health History/Intake Forms