Client Questionnaire | House for Positive Change

Your Contact Information

First Name

Last Name

Street Address

City

Phone/Whatsapp

Email

Birth Information

Place

Date

Exact Birth Time (from records if available)

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

Diet

What are your favorite foods and drinks?

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?

Daily Routine

What time do you typically go to sleep?

What time do you typically wake up?

Please describe the quality of your sleep

Do you meditate? If so describe type, frequency and times of practice.

What do you do for work?

What hobbies do you do have?

What are your favorite leisure activities?

What do you do for exercise?

Orientation of Home

Note: The easiest way to assess orientation is to google your address and check a map. True north will be at the top.

In what direction (e.g., N, S, E, W) do you face when you open the most frequently used entrance to your home?

In what direction does the head of your bed point when viewed from the feet end?

Social Situation

The easiest way to assess orientation is to google your address and check a map. True north will be at the top.

With whom do you live? How does that situation impact your health?

What is your education?

What is your religion?

Do you or anyone else in the household smoke or use tobacco products?

Yes No

Do you or anyone else in the household drink beverages containing alcohol?

Yes No

Do you or anyone else in the household use marijuana or other "recreational" drugs?

Yes No

Health History

Your Gender Identity

male Female Other: Please comment below

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

Have you ever suffered from abuse or other significant traumas? (check all that apply)

Emotional Physical Sexual

If so, please describe here or during your consultation as is comfortable

List any significant current and past medical problems for which you have received treatment including hospitalizations and surgery

List any significant current and past medical problems

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

Allergies

List any health problems that run in the family

Women's Reproductive

Date of Last Menstrual Period

What do you do for birth control?

Note any menstrual problems. Also, list your pregnancies with dates and outcomes.

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

For clients and prospective clients only: Do you wish to send a copy of your report to Elianne van Waalwijk van Doorn?

Yes

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