• Health Assessment Questionnaire

    Confidential Health Questionnaire
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  •  -
  •  -
  • Date of Birth
     - -

  • About your current issues

  • Medical History
  • Do you have a family history of any of the following?

  • Do you have any allergies?
  • As a child or in the past did you ever experience the following?

  • Digestion
  •    
  •    
  • How often do you pass a bowel motion?
  • Image field 115
  • Looking at the Bristol stool chart above, what is consistency of your bowel motions or what does it vary between?
  • Do you ever experience any of the following?

  • Immunity
  • Do you frequently experience any of the following?

  • Detoxification
  • Do you ever experience any of the following?

  • Energy and Sleep
  •    
  • Do you experience energy slumps during the day?
  • If you haven't eaten in a long time or have missed a meal, do you feel any of the below?
  • Do you ever crave any of the following?

  • With sleep, do you experience any of the following?

  • Hormonal System
    • Male 
    • Do you have or have you had any of the following:
    • Female 
    • Are you, or could you be pregnant?
    • Do you have any of the following:

    • Cycle

       

    • Prior to your period beginning do you experience any of the following:
    •    
    • Are there clots in your flow?

  • Musculoskeletal
  • Do you currently experience any of the following?

  • Mind & Emotions
  • Do you ever experience any of the following:
  •    
  • Have you ever had, past or present, any of the following:

  • Lifestyle

  • Diet

  • To understand you current diet, can you please give 2 x examples of what you eat for meals in a day, giving details on brands and types of food

  • On average, how many cups per day do drink of the following:
    Rows

  • The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it.

    We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements.

    We will not use or disclose your medical information for any purpose not listed below, without your specific written or verbal authorization. Any specific written authorization you provide may be revoked at any time by writing to us. With permission, we may use medical information about you to doctors, nurses, technicians, healthcare students, chiropractors, osteopaths or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

    CBD Natural Health

  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: