“There are no rules, only choices"Client Questionnaire Name * First Name Last Name Email Address * Address * Date of Birth * MM DD YYYY Gender * Male Female Occupation * Best Phone Number to Reach You * (###) ### #### Relationship Status * Single Married Divorced Widowed Domestic Partner Weight * Desired Weight * Height * Do you have children? * Yes No Currently in Physicians Care? * Please explain (medical/accupuncturist/herbalist/nutritionist/ psychotherapist) Purpose of Care with Above Physicians? * Please explain all ailments and which physicians are dedicated to what aspect Current Medications/herbs * Please list all medications/herbs prescribed by the above physicians. Medical History * Please check all that apply Abortion Anemia Arthritis Asthma Bleeding Tendency Bronchitis Cancer Chronic Fatigue Diabetes Digestive Disorder Emotional Problems Environmental Sensitivity Emphysema Epilepsy Headaches Heart Disease Hepatitis HIV Positive Hypertension Hypoglycemia Hypo-tension Injuries Insomnia Irregular Pregnancy Lung Disease Menstrual Irregularity Surgery Vaginal Infections Prostate Issues Do You Have Hepatitis? If yes please specify A B C No Are You Pregnant? * If you are a male, please check N/A Yes No N/A Surgeries/Biopsies * Please list all Treatment History * Please list any Chemotherapy and or Radiation treatments you have had and the dates. Or other treatments not mentioned. How or When Was Your Current Condition Diagnosed? * (Cyst, Tumor, Cancer) When Did You First Become Aware of This Condition? * Current Lifestyle * Check all that apply Tobacco Coffee Alcohol Recreational Drugs Birth Control Pills Hormone Replacement Prayer/Higher Power Relaxation/Meditation Vitamins/Supplements Current Diet Check all that apply Raw Foods Dairy Hot & Spicey Sugar Vegetarian Vegan Current Level of Pain or Discomfort 0 = No Pain / 10 = Unbearable Pain 0 1 - 3 4 - 7 8 - 10 How Many Times Per Day Do You Eat? 1 3 Many Do you eat breakfast on a regular basis? * If yes, please describe a typical breakfast. What Is A Typical Meal For You? Please be as detailed as possible. What time of day do you eat your last meal? * What Are Your Treat Foods? * List your top 3 go to treat foods for emotional eating and or snacking. Consumption of Fresh Fruits & Vegetables? * Always A few times per week Rarely Never What type of water do you drink and how many glasses per day? * Do You Eat Organic? * Yes Mostly Sometimes Rarely Are You In The Habit of Bringing Food From Home? * Yes No How Many Times Per Week Do You Eat Out? * 0 1 - 3 3 - 5 What Is A Typical Meal Ordered Out? * What Type of Animal Products Do You Consume? * i.e. dairy, red meat, chicken, fish, eggs Is The Animal Product You Consume Grass Fed and or Organic? * Yes No What Nationality of Food Did You Predominantly Grow Up Eating? * Please explain Do You Exercise? If Yes, How Often and What Type of Exercise? * Do You Have Any Joint or Muscle Pain? If Yes, Where? * How Is Your Energy Level? * Choose the one that most closely fits. High Moderate Low Do You Suffer From Depression? * Please explain in detail. Do You Suffer From Anxiety? * Please explain in detail. Emotional Environment * Please check all that apply. I Am Happy My Home Life Is Great I Love My Job My Current Mood/Emotional State is Great I Experience Recurring Emotional Patterns I Am Unhappy I Am Depressed I Feel Anxious Something is Missing in My Life Do You Suffer From Memory Loss * Please explain in detail. Please Describe All Allergies. * How Often Are Your Bowel Movements? Are They Easy or Hard? * Please be as detailed as possible. Do You Suffer From Emotional Eating Patterns Such as Binge Eating or Food Denial? * Please explain in detail. Why Have You Chosen The Private Mentorship Program? * What Are The Goals You Would Like To Reach During Our Time Together? * Are You Committed To This Process? * Yes No Kind of Commitment & Goals * Check All That Apply I Am Committed To Achieving My Goals, Whatever It Takes. I Trust Myself and My Choices and Will Do My Best. I Trust This Process and Know I Have Much To Work Through. I Believe In Myself Regardless of Any Challenges I May Face. Thank you! I will be in touch with you in the next 24 hours. To Health & Happiness,Gabrielle
