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HEALTH EVALUATION FORM

The following questionaire is a comprehensive look at your health. It will take about 5 minutes to complete

First name

Last name

Email

Gender

Male

Female

The condition you are seeking to treat

Level of health*

1 10

Level of energy or vitality*

1 10

Stress levels *

1 10

How many hours sleep do you get a night?*

Do you have trouble getting to sleep?*

Do you wake often, or get woken easily?*

Do you have to go to the bathroom during the night?*

Do you snore or have breathing problems during sleep?*

Do you have known allergies?*

Please list any medications you are currently taking

Please list any supplements you are currently taking

Do you have a main health complaint? Please describe.

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Do you exercise?*

Please list the types of exercise you do regularly

Do you smoke?*

Do you take recreational drugs?

Please list any food allergies / intolerances that you are aware of?

How many glasses of water do you have a day?*

Do you drink alcohol?

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Frequency of exercise (days per week):*

6 - 7

3 - 5

1 - 2

0

Vegetarian or vegen:*

Age >50 years:*

Planning to have a baby in the next 3-6 months:*

Pregnant or breastfeeding:*

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Are you unhappy with your weight?:*

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Would you like us to E-mail you a copy of your HAQ?*

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Finish

HEALTH EVALUATION FORM

GENERAL INFORMATION

Diet and lifestyle

Patient health history