Wellness Questionnaire

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Step 1 of 9

Personal Details

Name*

First Last

Age*

Weight*

Hight*

Date of birth*

Relationship status*

Occupation*

Email*

Phone*

Health

Date of last check-up: Medications being taken.*

Health Problems (past & current)*

Health problems in your family*

Do you take any supplements, medications, or herbs? List all supplements and medications you are taking. For each, specify name, the reason you are taking it, dose and frequency.*

How long have you been taking it?*

What differences have you noticed from the beginning and recently in taking them ?*

The problem you experienced is solved, or has it returned?*

Someone recommended or prescribed supplements or medications? Or was it self-prescribed?*

Do you take any supplements, medications, or herbs? List all supplements and medications you are taking. For each, specify name, the reason you are taking it, dose and frequency*

How long have you been taking it?*

What differences have you noticed from the beginning and recently in taking them ?*

Someone recommended or prescribed supplements or medications? Or was it self-prescribed?*

Please specify any allergies and intolerance for food.*

How it is your digestion? How many times during the day you go to the toilet? Specify quality of your bowel movements. Do you experience any bloating, inflammation, heartburn, gas, frequent burping, sluggish digestion, cramping/pain)?*

Do your bowel movements have odor? If yes, please describe. Is it sometimes or all of the time?*

Do you have diarrhea? If yes, how often?*

Do you have hemorrhoids? If yes, do they itch or bleed?*

Urine. Please specify color and how many times you go to the toilet?*

Menstrual Cycle. Please specify length, flow, timing and how is the texture of the blood.*

Sweat. Sweating is a natural process that helps regulate your body temperature and cool you down when you’re hot or exerting yourself. Please specify how it is your sweat.*

Do you usually feel cold, or warm in your body, or both?*

Do you feel you have strong immunity?*

How many colds/flus or illness do you get per year?*

Do you experience any symptoms such as cramping, numbness or tingling in the hands and feet, swelling around joints, memory loss or difficulty concentrating, fainting, digestive issues, fatigue, skin color changes, or varicose veins? If so, please specify.*

Does your skin tend to be dry, oily or moist?*

Is your skin texture thin, medium or thick?*

Any problems with your head, eyes, ears, nose, tongue or throat?*

How it is your sleep habits? Specify your schedule for sleeping.*

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Wellness Questionnaire

Personal Details

Health

Tongue

Diet

Lifestyle

Work

Relationships

Emotional and mental state.

Personality

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