Health History & Activity Questionnaire 

 
 
Name *
Name
There's no way around it, it's long, so please plan your time accordingly. Please allow 30 minutes to complete this questionnaire. In order for you to gain the most benefit from this program, we encourage you to answer all of the following questions to the best of your ability. The more I know about you the better I can help you. This questionnaire may seem redundant and that is intentional; I need you to recall every detail of your medical history to ensure I give you the best and most effective individual care. If you are uncomfortable answering a particular question, feel free to leave it blank. Please explain all YES answers in the space provided. **Please indicate RIGHT or LEFT side for all surgeries, pain, injuries etc.**
Please Check ALL that Apply - Have you ever been diagnosed as having any of the following conditions?
SKIN & BONES: Please Check ALL that Apply:
Do you currently have any medical conditions for which you see a physician regularly?
Do you currently experience any of the following symptoms in your legs of feet?
HEAD & NECK: Please Check ALL that Apply
VISION: Please Check ALL that Apply
RESPIRATION: Please Check ALL that Apply
BALANCE (VESTIBULAR, INNER EAR): Please Check ALL that Apply
TRUNK: Please Check ALL that Apply
GASTROINTESTINAL: Please Check ALL that Apply
CENTRAL NERVOUS SYSTEM: Please Check ALL that Apply
PAIN: Where in the Body are you Experiencing Pain?
Which ones BEST describe your pain:
Do you believe your pain can disappear for good?
Do you consider yourself an emotional eater?
Do you eat without any awareness when you are stressed?
Do you seek comfort in food?
Have you ever had an eating disorder?
My current diet could best be characterized as (check ALL that apply):
When it comes to your overall health which of the following are MOST important to you?