Client Follow-Up Questionnaire | House for Positive Change

Your Contact Information

First Name

Last Name

Phone/Whatsapp

Email

Purpose

What do you hope to get from this consultation?

Health Status

How would you rate your current state of health?

Very Poor Poor Fair Fairly Good Good Very Good Excellent

Do you agree with the following statement?

Stress is a big problem for me.

Strongle Disagree Disagree Somewhat Disagree Neutral Somewhat Agree Agree Strongly Agree

Interim Health Changes

Please describe any benefits you've enjoyed from Ayurvedic recommendations. Highlight any problems not listed above that still need attention.

Please describe any benefits you've enjoyed from Ayurvedic recommendations

List all your current medications, herbs, vitamins and supplements including dose and frequency. You may use the key to make a new row after each entry.

List all your current medications, herbs, vitamins and supplements including dose and frequency.

Diet

List everything that you ate and drank in the last 24 hours and the time it was consumed in the format: Time | Food Eaten

Use the key to make a new row after each entry.

Do you agree with the following statement?

I love to cook.

Strongle Disagree Disagree Somewhat Disagree Neutral Somewhat Agree Agree Strongly Agree

Who cooks most of your food?

Units of Measurement for both Weight and Height

English Metric

Your Weight (use lb or kg): 100 lbs = 45 kg

Your Height (use inches or cm): 60 inches = 5 feet = 152 cm

Comments

Do your responses reflect your situation and represent permission to use your de-identified data in aggregate scientific studies? Clients should be able to comfortably answer yes. If not, please call to discuss.

Yes No

Clarifications, Comments or Questions