PATIENT QUESTIONNAIRE
Please complete the following
form before attending your treatment. Please give as much
detail as possible.
Name:
Address:
Telephone numbers:
Email address:
Date of Birth:
Height:
Weight:
Marital Status/Domestic circumstances:
Please give details (age and gender) of any children you
have:
Are you pregnant? If yes, how many weeks?
Occupation:
How much do you enjoy your work?
Do you smoke? How many a day?
Do you drink alcohol? How many units per day?
Left or right handed?
Are you on any medication? If yes, please give details:
G.P’s Name and Address:
Please give details of any illness, condition, injury,
addiction or disease that you have suffered from, or
currently suffer from, and any traumatic experiences that you
can remember or have been told about, even if you can’t
consciously remember them.
FOOD AND
DIGESTION
Please give a description of your normal diet, including all
fluids.
Feel free to keep a food diary for a week or two before your
treatment and be honest!
How much water do you drink each day?
What other drinks do you consume and how much? e.g coke,
fizzy drinks etc?
Do you have any special dietary requirements or restrictions?
If yes, please describe.
Do you suspect you are sensitive to any particular foods? If
yes, please list them below.
Do you take any nutritional or herbal supplements? If yes,
please give details.
PLEASE
BRING ALONG ANY SUPPLEMENTS YOU HAVE
How often do you open your bowels and do you find it easy
when you do?
Do you suffer from any digestive problems? (eg, indigestion,
heartburn, bloatedness, wind, constipation, diarrhoea)?
If yes, please give details.
GENERAL HEALTH
AND WELLBEING
Do you suffer from any pain or discomfort anywhere in your
body? If yes, please give details.
Do you tend to succumb to colds/infections? If yes, how often
and how severely?
Are there any particular health problems (physical or mental)
that you would like to deal with?
If yes, please give details.
How energetic do you feel throughout the day?
Do you ever feel lethargic or lacking in energy at any
particular time of the day?
Do you exercise regularly? Please state exercise and
regularity?
How do you like to relax? And how often do you achieve it?
How well do you sleep? Do you wake up feeling refreshed or
groggy and tired?
Do you suffer from headaches/migraines? If yes, please
describe symptoms and or any triggers?
Do you ever feel stressed? If yes, how often and to what
level?
What do you do to try to reduce your stress levels? Are you
aware of any triggers that cause your stress?
How would you describe your general health?
How content and happy are you with your life generally?
What would you like to gain from this treatment?