Health Assessment Intake Questionnaire [52 questions] | Practice

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Health Assessment Intake Questionnaire

Are you a professional looking for a comprehensive way to assess the overall health of your clients? The Health Assessment Intake Questionnaire is the perfect tool for you.

This questionnaire is designed to provide you with a comprehensive overview of your client’s physical, mental, and emotional health. It includes questions about diet and lifestyle, fitness and exercise, medical history, mental health and stress, and more.

The questionnaire is easy to fill out and provides detailed results that you can use to develop a personalized plan that best meets your client’s needs. This questionnaire is also a great way to build trust and create an open dialogue between you and your client.

The Health Assessment Intake Questionnaire is the perfect tool for professionals who are looking for a comprehensive way to assess their client’s overall health. With detailed results and an easy-to-use format, this questionnaire is the ideal tool for any professional looking to provide their clients with the best care possible.

Health Assessment Intake Questionnaire

Describe Problem(s):

What treatments have you tried?

Has anything been successful?

With whom do you live?

Do you have any pets or farm animals? If yes, where do they live?

Have you lived or traveled outside of the United States? If so, when and where?

Have you or your family recently experienced any major life changes? If yes, please explain:

Have you experienced any major losses in life? If so, please explain:

How much time have you lost from work or school in the past year?

List past Medical and Surgical History:

List previous hospitalizations:

How often have you taken antibiotics?

How often have you have taken oral steroids?

What medications are you taking now?

List all vitamins, minerals, and other nutritional supplements that you are taking now.

Were you a full term baby? A preemie? Breast- fed or Bottle-fed?

As a child did you eat a lot of sugar and/or candy?

What is your typical daily diet:

How many Caffeinated Beverages do you consume each week? (1 low to 5 high)

How much Dairy do you consume each week? (1 low to 5 high)

How much Cheese do you consume each week? (1 low to 5 high)

How much Bread do you consume each week? (1 low to 5 high)

How much Sugar do you consume each week? (1 low to 5 high)

How much Candy do you consume each week? (1 low to 5 high)

How much Dessert do you consume each week? ( 1 low to 5 high)

Is there anything special about your diet that we should know?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)?

Do you feel much worse when you eat certain foods?

Do you feel much better when you eat certain foods?

Does skipping a meal greatly affect your symptoms?

Have you ever had a food that you craved or really "binged" on over a period of time?

Do you have an aversion to certain foods? If yes, what foods?

How many bowel movements (BM) do you have per day?

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?

Do you have intestinal gas? If so, when.

How many times per week do you drink alcohol?

Have you ever used recreational drugs?

Have you ever used tobacco? (If so, for how long?)

Are you exposed to secondhand smoke regularly?

Do you have mercury amalgam fillings in your teeth? If so, how many?

Do you have any artificial joints or implants? If so, which ones.

Do you feel worse at certain times of the year?

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

Do odors affect you? If so, which ones?

How would you rate your current level of stress?

Have you ever had psychotherapy or counseling?

Are you currently, or have you ever been, married?

Do you have any children? If so, what are the ages?

List your hobbies and leisure activities:

Do you exercise regularly? If so, how many times a week? What type of exercise is it?

Do your parents or siblings have (or had) any health issues? If so, please explain:

 Congratulations, you are on the path to taking your first step towards health and wellness! I have read and understand everything on this page. I acknowledge Steffanie Housman and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Steffanie Housman, her lab partners, her independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.  Please check the box below if you agree.

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