JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
HEALTH INTAKE QUESTIONNAIRE
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
FIRST NAME
*
Your answer
LAST NAME
*
Your answer
ADDRESS
*
Your answer
CITY
*
Your answer
POSTAL CODE
*
Your answer
EMAIL ADDRESS
*
Your answer
PHONE NUMBER
*
Your answer
BIRTH DATE
*
MM
/
DD
/
YYYY
PLACE OF BIRTH
*
Your answer
HEIGHT
*
Your answer
WEIGHT
*
Your answer
GENDER
*
Your answer
OCCUPATION
*
Your answer
REFERRED BY
*
Your answer
TODAY'S DATE
*
MM
/
DD
/
YYYY
DESCRIBE PROBLEM
*
Your answer
What treatments have you tried?
Your answer
Has anything been successful?
Your answer
With whom do you live?
Your answer
Do you have any pets or farm animals? If yes, where do they live?
Your answer
Have you lived or traveled outside of your home country? If so, when and where?
Your answer
Have you or your family recently experienced any major life changes? If yes, please comment:
Your answer
Have you experienced any major losses in life? If so, please comment:
Your answer
How much time have you lost from work or school in the past year?
Your answer
Previous jobs:
Your answer
Did you feel safe growing up?
Your answer
Have you been involved in abusive relationships in your life?
Your answer
Was alcoholism or sub-stance abuse present in your childhood home, or is it present now in your re-lationships?
Your answer
Do you feel safe, respected and valued in your current relationship?
Your answer
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
Your answer
Would you feel safer dis-cussing any of these issues privately? Would you prefer not to speak about these issues?
Your answer
List past Medical and Surgical History:
Your answer
List previous hospitalisations:
Your answer
How often have you taken antibiotics?
Your answer
How often have you have taken oral steroids?
Your answer
What medications are you taking now?
Your answer
List all vitamins, minerals, and other nutritional supplements that you are taking now.
Your answer
Were you a full term baby? A pre-mature baby? Breast-fed or Bottle-fed?
Your answer
As a child did you eat a lot of sugar and/or candy?
Your answer
How much of the following do you consume each week? (Tea, Coffee, Soda, Other Caffeine, Dairy, Cheese, Bread, Sugar, Candy/Chocolate, Dessert)
Your answer
Are you on a special diet?
Your answer
Is there anything special about your diet that we should know
Your answer
Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)?
Your answer
Do you feel much worse when you eat certain foods?
Your answer
Does skipping a meal greatly affect your symptoms?
Yes
No
Other:
Clear selection
Have you ever had a food that you craved or really "binged" on over a period of time?
Your answer
Do you have an aversion to certain foods? If yes, what foods?
Your answer
How many bowel movements (BM) 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
Have you ever used recreational drugs?
Your answer
Have you ever used tobacco? (If so, for how long?)
Your answer
Are you exposed to secondhand smoke regularly?
Your answer
Do you have mercury amalgam fillings in your teeth? If so, how many?
Your answer
Do you have any artificial joints or implants? If so, which ones.
Your answer
Do you feel worse at certain times of the year?
Your answer
Have you, to your knowledge, been exposed to toxic metals in your job or at home?
Your answer
Do odors affect you? If so, which ones?
Your answer
How would you rate your current level of stress?
Least Stressful
1
2
3
4
5
Most Stressful
Clear selection
Have you ever had psy-chotherapy or counseling?
Yes
No
Other:
Clear selection
Are you currently, or have you ever been, married?
Your answer
List your hobbies and leisure activities:
Your answer
Do you exercise regularly? If so, how many times a week?
Your answer
What type of exercise is it?
Your answer
Do your parents or siblings have (or had) any health issues? If so, please explain:
Your answer
What are your top 3 goals that you would like me to help you work on?
Your answer
Why do you believe you would be a good candi-date to work with Janice?
Your answer
I have read and understand everything on this page. I acknowledge that Janice Tan is a natural health practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Janice Tan, her lab partners, her independent representatives, associates and affiliates 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.
Yes, I have read and acknowledged
No
Clear selection
Congratulations, you are on the path to taking your first step towards health and wellness!
We will get back to you shortly!
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
