Health Intake Questionnaire Template [51 questions]

User Generated Form

Health Assessment Intake Questionnaire

This questionnaire is an essential part of the process for assessing the health of your clients. It is designed to provide an understanding of your client's overall health, medical history, current lifestyle, and any health issues they may be experiencing.

The questionnaire allows you to learn about the client's current health concerns, past medical history, and how those health concerns may be impacting the client's daily life. Questions about family medical history and existing medical conditions help to provide a more complete picture of the client's overall health. Additionally, the questionnaire covers topics related to lifestyle and nutrition, providing you with the information you need to create a well-rounded plan to help your client achieve optimal health.

The questionnaire is designed to be easy to complete and provides a convenient way to collect information from your clients. The data collected can be used to develop a plan that is tailored to your client's individual needs. With the information gathered, you are better able to identify and address any potential health issues early, while also providing a comprehensive approach to improving your client's overall wellbeing.

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:

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Health Assessment Intake Questionnaire

Health Assessment Intake Questionnaire

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