New Client Questionnaire
Full Name
*
First Name
Last Name
Postal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
Current Age
*
What is your Gender?
*
Male
Female
Other
What is your occupation?
What are your current health concerns? Please list in order of importance:
*
Please describe any triggers associated with the main complaint at the time of occurrence:
Was there any mental, physical or emotional distress around the onset of a condition?
Please list any other concurrent therapies:
What are your health goals? (e.g. relief from chronic health issues, detox, better sleep, stress relief, weight loss):
*
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Please rate the following:
Energy Level on Average
*
(1-10, 1 = very low, 10 = very good/high)
Comments:
Mental Clarity/Brain Fog on Average
*
(1-10, 1 = very poor, 10 = very clear)
Comments:
Sleep Quality on Average
*
(1-10, 1 = very poor, 10 = very good/sound)
Comments:
When do you go to sleep on average?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Do you have trouble falling asleep?
*
Yes
No
When do you wake up on average?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Do you wake up during the night?
*
Yes
No
If yes, at what time(s)?
Do you wake up feeling rested?
*
Yes
No
How many hours do you exercise each week?
What type of exercise do you do?
Sense of Joy/Well-being/Contentment on Average
(1-10, 1 = very poor, 10 = very good)
Comments:
Pain Level on Average
(1-10, 1 = very poor, 10 = very good)
Comments:
(Pain location, type, severity, known causes)
Overall Stress Level
*
(1-10, 1 = super stressed, 10 = feeling calm and balanced)
Please describe the key causes of Stress:
*
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Next
Do you follow a special diet?
Please describe a typical breakfast:
*
Please describe a typical lunch:
*
Please describe a typical dinner:
*
Please describe typical daily snacks:
*
Please list the most frequent fruit and Vegetables eaten:
*
How often do you eat take away, and what type?
How often do you drink alcohol?
Every day
2 to 3 times a week
Rarely
Never
How many alcoholic drinks do you consume on average when drinking?
How much water (in litres) do you drink per day?
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Do you experience digestive troubles? Please mark all that apply:
*
Bloating
Burping
Cramps
Constipation
Gas
Diarrhea
Heartburn
Nausea
Painful bowel movements
Phlegm in throat
Black stools
Undigested food in stool
Mucous in stool
None
How frequently do you experience the above symptoms?
Do you have/have you had any of the following conditions? Please mark all that apply:
*
Current
Past
Acne
ADD/ADHD
Addictions
Anemia
Anxiety
Appendicitis
Arthritis
Asthma
Candida
Cancer
Celiac Disease
Colitis
Concussion
Crohn's Disease
Depression
Type I Diabetes
Type II Diabetes
Eczema
Fatigue
Fibroids (uterine)
Fibromyalgia
Gallbladder taken out
Gallstones
Heart attack
H. Pylori
Hypertension
Hyperthyroid/Graves' Disease
Hypothyroid/Hashimoto's
IBS
Kidney disease
Kidney stones
Liver disease
Parasites
Psoriasis
Poor memory
Seizures
Sinus infections (recurrent)
SIBO
Stressed easily
Stroke
Thyroid Conditions (other)
Tonsillitis
Viruses
Ulcers
None
Please indicate any immediate relatives who have or have had the preceding medical conditions:
Have you been hospitalized for a serious condition or had major surgery? List reason(s) and date(s):
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Next
Do you take or use any of the following, or have you taken them in the past? Please mark all that apply:
*
Current
Past
Allergy medications
Antacids
Antibiotics
Antidepressants
Anti-fungals
Anti-inflammatories or NSAIDs
Birth control pills
Blood Pressure Medication
Cholesterol Medication
Cortisone
Diet pills
Diuretics
Enzymes for digestion
HCl (Hydrochloric acid for digestion)
Human Growth Hormone
Hormone replacement
Laxatives
Probiotics
Sleeping pills
Stool softener
Thyroid medication
Other
None
Please list the names of medications, vitamins, or supplements that you are currently taking. Please include dose, brand, how often you take them, and for how long (years/months):
Please list any medications that you have taken in significant amounts or for a long past duration (e.g. "birth control pills from age 19-34" or "acid blockers 3x/day for 5 years"):
Have you had any concerning or negative reactions to medications or supplements?
Cigarette use:
1-5 per day
5-10 per day
More than 10 per day
Quit
Never
If you previously smoked, how long since quitting?
Is there anything else that I should know about you?
By submitting this form, I assert that I have read and agree to the following: This health assessment is to gather relevant information relating to your current health prior to consultation. Marchant's Nutritional Therapies, and/or Bec Marchant do not claim to absolutely diagnose or cure any disease, illness or condition. Any information provided is intended to help guide informed decisions about your personal health. Bec Marchant is a registered Nutritionist, and provides health advice based on the information provided to the best of her knowledge and abilities. The information, products, and services provided by Marchant's Nutrition are intended to support health and wellness and are not intended to replace the ongoing support and advice of your treating physician. Your personal health records are kept digitally and are not shared unless required by law.
*
Yes, I agree.
Submit
Thank you for your time and input! We will discuss more in person.
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