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Client Consultation Questionnaire

 
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CombinedNSP
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Joined: 13 Dec 2006
Posts: 1406
Location: Cleveland, OH

PostPosted: Dec Sat 16, 2006 1:45 pm    Post subject: Client Consultation Questionnaire Reply with quote

Client Consultation Questionnaire

Here is the client Consultation Questionnaire that we use.
Name _______________________________ Date ___________
Age ______ Sex _____
Address ___________________________ City __________
State __Zip _____ __

Phone #(Day): _____________(Night): _______________ (Fax):___________

Height ____ Weight _____
Occupation ____________________________

Who Referred You _____________________________________

Do You: Smoke Yes No How Much _______________________

Drink Coffee Yes No How Much __________________________

Use Dairy Products Yes No How Much _____________________

Drink Soda Pop Yes No How Much ________________________

Drink Liquor Yes No How Much __________________________

Drink Water Yes No How Much __________________________

Birth Control Pills Yes No How Long ______________________

List All Medicine You Take ____________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________

List All Surgical Operations You Have Had And What Organs Have Been Removed ____________________________________________________
Do You Exercise Regularly? Yes No How?
How Many Bowel Movements Do You Have a Day? _____ Are You Pregnant? Yes No
How Long Has it Been Since You Had a Sulpha Drug, Birth Control Pills, or an
Anti-biotic? _____________ For What? _______________________

List Any Diseases That You Have: _______________________________________________
Major Complaints: Please Check Problem Areas; Double-check Those That You Wish to Deal with First.
Lack of Energy
Headaches
Backaches Where
Weight Problems
High Blood Pressure
Low Blood Pressure
Heartburn
Low Sex Drive
Frequent Infections
Poor Circulation
Cold Hands & Feet Food Allergies
Sinus Problems
Asthma
Gas
Bloating
Water Retention
Diarrhea
Painful Joints
Irritable And/or Depressed
Loss of Memory
Menstrual Problems

List Any Additional Complaints:
-Kay Lubecke
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