awaken your health: client questionnaire

age *
date of birth *
how to make your date selection quickly
are you happy to receive AYH quarterly newsletters, including recipes and specials? * yes no
do you have any children? * yes no
your occupation? *

how did you hear about awaken your health? *
please list the main problems you are experiencing
and/or reasons for this appointment.
*
what do you believe the problem may be due to? *
what kind of treatment(s) have you tried for the problem(s) listed above?
*
please detail any relevant testing or investigations and bring copies of the results to your consultation.

what are your long term health goals? *
what three things would you most like to improve
about your health over the next few weeks?
*
do you have any other existing medical conditions or injuries?
If so, please list:
*

are you currently taking any medications?
Please specify dosage, brand and quantity: *
(eg: anti-inflammatories/pain relief/contraceptive pill)
are you currently taking any supplements or herbal medicines?
Please specify dosage brand and quantity: *
do you have any known allergies? *
how would you rate your general energy levels?
(score out of 10)
do you feel your energy levels drop within an hour of eating? *
do you have cravings for sweets, pastries, cakes, chocolate?
how many hours of sleep would you have each night on average? *
how would you rate your daily stress levels? * low medium high

what is your current weight?
what is your goal weight?
do you smoke? (if so, how many daily?) *
are you an ex-smoker? (when did you quit?)
do you suffer from any of the following symptoms regularly? *
(Select all that apply)
Hold down Control (PC)/Command (Mac) to make multiple selections
what do you do for exercise?
how often?
what do you do for relaxation?
how often?

how often do you usually eat fried foods? *
how many serves of bread, pasta, rice, potatoes or other starchy foods do you have a day? *
how many teaspoons of sugar do you consume daily in hot drinks, added to foods, etc *
how often do you usually eat canned or fresh fish? *
how many pieces of fresh fruit do you usually eat a day? *

how many servings of vegetables do you usually eat a day (excluding potatoes)? *
how many cups of coffee do you usually drink a day? *
how many cups of tea do you usually drink a day? *
how much soft-drink do you consume on average? *
how much water do you drink a day? *

family health medical tree

Please complete the chart below indicating only chronic or significant illnesses. To make multiple selections hold down command (⌘) on the Mac or Control on PC. iOS devices - tap one selection with one finger then use another finger to make the other selections.

The family members highlighted in yellow relate to your fathers family, the pink highlights relate to your mothers family