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Health Intake Questionnaire
Confidential Health Questions. Please fill out to your level of comfort.
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Name
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Your answer
Date
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MM
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DD
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YYYY
Email
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Your answer
Address
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Your answer
Phone number
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Your answer
Time Zone
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Your answer
Date of Birth
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MM
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DD
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YYYY
Height/Weight
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Your answer
Occupation
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Your answer
Referred By
Your answer
Describe Problem(s):
Symptom(s):
Example: Bloating, Gas, Hot Flashes, Skin Rashes, Joint Pain, Brain Fog, Weight Gain/loss
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Your answer
Do you sleep 7-9 hours per night?
Yes
No
Some night are better than others
Clear selection
Do you wake up during the night, and can't fall back asleep?
Yes
No
Often
Most night are restful but I experience this from time to time
Have you or your family recently experienced any major life changes? If yes, please comment:
Your answer
Have you been exposed to mold?
Yes
No
Not to my knowledge
Describe your "normal" emotional state of mind. Ex: Happy, Sad, Angry etc.
Your answer
Have you had any violent or otherwise traumatic life experiences?
Yes
No
If so, would you prefer not to speak about these issues?
Yes, I would NOT like to speak about them.
No, we can discuss in private during our consultations as needed.
List past Medical and Surgical History/Hospitalizations:
Your answer
Have you taken antiboitics in your life?
Yes
No
If so, how long ago?
Your answer
What medications are you taking now? This is important when making supplement recommendations. If not, please answer NO.
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Your answer
List all vitamins, minerals and other nutritional supplements that you are taking now.
Your answer
What is your typical daily diet? Be specific.
Your answer
Do you consume the following daily?
Tea
Coffee
Soda
Other Caffine
Dairy
Cheese
Bread
Sugar
Candy/Chocolate
Dessert
Do you consume the following weekly?
Tea
Coffee
Soda
Other Caffine
Dairy
Cheese
Bread
Sugar
Candy/Chocolate
Dessert
Do you have symptoms immediately after eating? Ex: Belching, bloating, sneezing, hives, etc.?
Your answer
What specific diets have you tried? Ex: Keto, Vegan, Low Carb etc?
Your answer
Do you have an eating disorder?
Yes
No
Clear selection
Do you feel worse when eating certain foods?
Your answer
Does skipping a meal greatly affect you mood or energy levels?
Yes
No
I'm not sure
Do you have food cravings? If so, what?
Your answer
Do you have an aversion to certain foods? If yes, what foods?
Your answer
How many bowel movements do you have per day?
Your answer
Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?
Your answer
Do you have intestinal gas? If so, when?
Your answer
How many times per week do you drink alcohol?
Your answer
Are you exposed to second hand smoke regularly?
Yes
No
Do you smoke cigarettes or vape?
Yes
No
Do you have mercury amalgam fillings in your teeth? If so, how many?
Your answer
Do you feel worse at certain times of the year?
Yes
No
Clear selection
Have you, to your knowledge, been exposed to toxic metals in your job or at home?
Yes
No
Do odors affect you? If so, which ones?
Your answer
How would you rate your current level of stress? 1 - low, 10 high
1
2
3
4
5
6
7
8
9
10
Clear selection
Do you see a therapist?
Yes
No
Clear selection
List you hobbies and leisure activities:
Your answer
Emotional Balance: Do you experience any of the following?
Bitterness
Resentment
Discomfort
Anger
Disappointment
Guilt
Shame
Anxiety
Sadness
Do you exercise? If so, what do you like to do? How many times per week?
Your answer
Do you track your calories or macronutrients?
Your answer
What is your top goal? Find Root Cause? Lose Weight? Symptom relief?
Your answer
Congratulations, you are on the path to taking the next step in your health and wellness journey!
Please add name and date below.
I have read and understand everything on this page. I acknowledge Karre Ozyuk of High Vibe Health Coaching, LLC. as an natural health practitioner and does not diagnose, treat or cure any illness or disease. Futher, the under-signed releases Karrie Ozyuk of High Vibe Health Coaching, LLC from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.
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