CombinedNSP Site Admin
Joined: 13 Dec 2006 Posts: 1406 Location: Cleveland, OH
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Posted: Dec Sat 16, 2006 1:45 pm Post subject: Client Consultation Questionnaire |
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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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