Wholistic Living Where Joy Comes Naturally
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- Lorena Oliver
- 5 years ago
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1 Coaching Intake Form Wholistic Living Where Joy Comes Naturally The questions in this form are designed for you to bring to the surface a description or picture of the current state of your life, your perspective and vision. This is your opportunity to begin designing the way of life that really works for you. This information is helpful for me to understand who you are, and how I can best coach you in developing realistic goals and support your emotional needs. 1. Contact Data & General: Your Name: _ Mailing Address: Home Phone: Cell Phone: Address: Date of Birth: Age: Marital Status: Spouse s Name: Children s Names and Ages: Company Name: Title: Business Phone: 2. Your Goals: What are the biggest changes you want to make in your life in the next 3 months? What are the biggest changes you want to make in your life over the next 3 years? What, if any, are the barriers which prevent you from achieving these things? What would you say have been your 3 greatest accomplishments to date? EXPECTATIONS: What do you expect to achieve in life as a result of hiring me as your life coach?
2 3. Your History: What is the hardest thing in your life that you have had to overcome? How did you do it? What major transitions have you had in the past two years? (Example: Entering or approaching a different age, a new or different relationship, job role, a move, a change in children s ages/stages, etc.) Who are or have been your major role models? Why? Have you worked with a coach before or a similar one-on-one adult relationship (e.g. Soccer coach, piano teacher, and therapist)? If so, what worked well for you and what did not work in the relationship(s)? Your Life Story / History: What would you like to share with me?
3 4. Improvements: Please list any improvements you would like to make in the following areas: Family: Health/Self Care: Career/Business life: Relationships (intimate and friendships): Living Space/Home: Service/Personal Growth/Learning: Creativity: Play / Leisure time: Other areas: 5. Your Life: Who are the key people in your life and what do they provide for you? What is your favorite part of your typical day? Why? What is your least favorite part of your typical day? Why? Looking at the past six months of your life, do you like the direction your life is moving in? Explain. Do you feel your life is one of your choosing? If not, which parts are being chosen for you? What is a dream or goal you have given up on? What do you think is NOT possible to achieve in your lifetime that you wish you could?
4 What part of yourself, if any, have you given up on? On a scale of 1 to 10 with 10 high, rate the quality of your life today. 6. Health and Social History: How tall are you? How much do you weigh? What size clothes do you wear? Shirts: Pants: In the greatest detail possibly please describe what you eat and drink for: Breakfast: Lunch: Dinner: Snacks and any other time: What do you feel is your biggest weakness with food? (dessert, soda, candy, French fries) Who is your primary physician? When was your last Physical? Do you drink alcohol? How much? How Often? Do you smoke cigarettes? How much? How Often? Do you consume caffeine? How much? In what form? Have you been diagnosed with any chronic health conditions (heart disease, high blood pressure, high cholesterol, autoimmune disorders, asthma, allergies, etc)? Please list any and all medications that you take on a regular basis including supplements: Name of Medicine Dose of Medicine What is it for? Who Prescribed it?
5 Do you exercise? How often? For how long? What type of exercise do you do? Do you enjoy other types of physical activity? (Such as hiking, gardening, yard work, organized sports, etc.) Do you belong to a gym? Or have exercise equipment in your home? What barriers do you have to exercise? Do you use electronic devices? Which ones? (Cell phone, texting, Face Book, gaming, etc) Do you ever feel that your use of these things is causing a problem in your life? 7. Tolerations: List five things that you re personally tolerating or putting up with in your life at present. (Examples: clutter, rude friends, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, cranky people in your life, kid stressors, overscheduled, etc.) In a typical week, what do you spend a great amount of time doing? What are your primary stressors? (What stresses you out?) On a scale of 1 to 10, 10 high, rate the amount of stress in your life right now. 8. Potential and Possibility: If you could develop a personal or professional vision for yourself what would it be? What would you like to give others (friendship, love, kindness, service, support, money, etc)? What would be your personal or professional legacy, which you would give to others, when the day s and seasons are over, when it s all been said and done?
6 What do you know for sure? 9. Other Background: Hobbies: What do you spend most of your leisure time doing? Who do you spend most of your leisure time with?
7 Candida Questionnaire and Score Sheet Candida albicans can affect the digestive tract and the body as a whole. Although it is normal to have a certain level of Candida present in the body, certain factors can lead to a Candida overgrowth that can contribute to a wide variety of symptoms and conditions. This Questionnaire is a tool to evaluate the likelihood of whether Candida may be playing a role in your health. With a positive result from the questionnaire, more specific testing is used verify the presence or absence of Candida in your body. Questions in Section A focus on your medical history factors that promote the growth of Candida albicans and that frequently are found in people with yeast-related health problems. In Section B you ll find a list of 23 symptoms that are often present in patients with yeast-related health problems. Section C consists of 33 other symptoms that are sometimes seen in people with yeast-related problems yet they also may be found in people with other disorders. Filling out and scoring this questionnaire should help you evaluate the possible role Candida albicans contributes to your health problems. Yet, it will not provide an automatic yes or no answer. Section A: History Circle the points for each question if it is a yes answer. Point Score 1. Have you taken tetracyclines or other antibiotics for acne for 1 month (or longer)? Have you at any time in your life taken broadspectrum antibiotics or other antibacterial medication for respiratory, urinary or other infections for two months or longer, or in shorter courses four or more times in a one-year period? Have you taken a broad-spectrum antibiotic drug even in a single dose? 6 4. Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs? Are you bothered by memory or concentration problems do you sometimes feel spaced out? Do you feel sick all over yet, in spite of visits to many different physicians, the causes haven t been found? Have you been pregnant... Two or more times? 5 One time? 3
8 8. Have you taken birth control pills... For more than two years? 15 For six months to two years? 8 9. Have you taken steroids orally, by injection or inhalation? For more than two weeks? 15 For two weeks or less? Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke... Moderate to severe symptoms? 20 Mild symptoms? Does tobacco smoke really bother you? Are your symptoms worse on damp, muggy days or in moldy places? Have you had athlete s foot, ring worm, jock itch or other chronic fungous infections of the skin or nails? Have such infections been... Severe or persistent? 20 Mild to moderate? Do you crave sugar? 10 TOTAL SCORE, Section A Section B: Major Symptoms For each of your symptoms, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild points If a symptom is frequent and/or moderately severe... 6 points If a symptom is severe and/or disabling... 9 points Add total score and record it at the end of this section. Point Score 1. Fatigue or lethargy 2. Feeling of being drained 3. Depression or manic depression
9 4. Numbness, burning or tingling 5. Headache 6. Muscle aches 7. Muscle weakness or paralysis 8. Pain and/or swelling in joints 9. Abdominal pain 10. Constipation and/or diarrhea 11. Bloating, belching or intestinal gas 12. Troublesome vaginal burning, itching or discharge 13. Prostatitis 14. Impotence 15. Loss of sexual desire or feeling 16. Endometriosis or infertility 17. Cramps and/or other menstrual irregularities 18. Premenstrual tension 19. Attacks of anxiety or crying 20. Cold hands or feet, low body temperature 21. Hypothyroidism 22. Shaking or irritable when hungry 23. Cystitis or interstitial cystitis TOTAL SCORE, Section B
10 Section C: Other Symptoms For each of your symptoms, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild... 1 point If a symptom is frequent and/or moderately severe... 2 points If a symptom is severe and/or disabling... 3 points Add total score and record it at the end of this section. Point Score 1. Drowsiness, including inappropriate drowsiness 2. Irritability 3. Incoordination 4. Frequent mood swings 5. Insomnia 6. Dizziness/loss of balance 7. Pressure above ears... feeling of head swelling 8. Sinus problems... tenderness of cheekbones or forehead 9. Tendency to bruise easily 10. Eczema, itching eyes 11. Psoriasis 12. Chronic hives (urticaria) 13. Indigestion or heartburn 14. Sensitivity to milk, wheat, corn or other common foods 15. Mucus in stools 16. Rectal itching 17. Dry mouth or throat 18. Mouth rashes, including white tongue
11 19. Bad breath 20. Foot, hair or body odor not relieved by washing 21. Nasal congestion or postnasal drip 22. Nasal itching 23. Sore throat 24. Laryngitis, loss of voice 25. Cough or recurrent bronchitis 26. Pain or tightness in chest 27. Wheezing or shortness of breath 28. Urinary frequency or urgency 29. Burning on urination 30. Spots in front of eyes or erratic vision 31. Burning or tearing eyes 32. Recurrent infections or fluid in ears 33. Ear pain or deafness TOTAL SCORE, Section C Total Score, Section A Total Score, Section B GRAND TOTAL SCORE The Grand Total Score will help you and your physician decide if your health problems are yeast-connected. Scores in women will run higher, as seven items in the questionnaire apply exclusively to women, while only two apply exclusively to men.
Section A: History. 1. Have you taken tetracyline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotic for acne for 1 month or longer?
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611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:
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Wisconsin Integrative Pain Specialists
Patient Information Today s Date: Patient s Name: DOB: Age: Gender: Marital Status: M S D What would you like us to call you? Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email: Preferred
Holistic Health Care New Patient Intake Form
Holistic Health Care New Patient Intake Form Name * Address * Telephone number: * Email Address * May we use your email address occasionally for health related information? * Are you a current or past
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:
Name: Date of Birth: Age: Address: City State Zip
Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership
Health History Questionnaire Name Date Age Date of Birth Gender Married Single Separated Divorced Widowed Partnership Live with: Spouse Partner Parents Children Friends Alone Please complete these next
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Patient History (Please Print)
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HEALTH QUESTIONNAIRE (In strictest confidence)
0115 882 0292 www.gedlingcolonics.co.uk jane@gedlingcolonics.co.uk HEALTH QUESTIONNAIRE (In strictest confidence) Please save this document, complete, save and return to us by email or post. Alternatively
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions
New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip
About You Pulley Chiropractic & Acupuncture, LLC Janine Pulley, D.C., L.Ac. 102 Peters Street, Suite 1, North Andover, MA 01845 P: 978-237-5106 * F: 978-420-4399 drjanine@pulleychiropractic.com * www.pulleychiropractic.com
Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX
Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX 77375 281.290.0531 www.feelwellagain.com FEMALE MEDICAL QUESTIONNAIRE (POSTMENOPAUSAL) NAME: DATE OF BIRTH: CHIEF COMPLAINT What is your primary
ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No
ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) E-mail Yes No (if you would like email appointment reminders) May we email you
Patient Health History Form
Thomas S. Burgoon, M.D. West Chester, PA 19382 Patient Health History Form Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient