Life-Style Counseling Questionaire

Life-Style Change Consultation Questionnaire

Note: This form requires using the Internet Explorer browser. If you're using a different browser or if you're uncomfortable about submitting this on-line, you can click here to download a printable version of this questionnaire which you can fill out and fax or mail back to us.

Having trouble sending this form?

Date:

Full name:

Birth Date:

Age:

Street:

Daytime phone w/area code:

City:

Evening phone w/area code:

State:

Zip:

Email:

Occupation:

Please check any of the following that apply to you:

Acute Pain	Eye Problems	Please describe any other condition:
Allergies	Failing Memory
Arthritis	Headaches
Cancer	Heart Ailment
Chronic Fatigue	High Blood Pressure
Diabetes	Osteoporosis
Difficulty Sleeping	Skin Disorder

Answer the following questions as best you can:

Are you presently taking any prescription medications? If so, please describe:

Please describe your current level of health and fitness

Please list your present symptoms of pain or discomfort

Do you eat meat? What kind? How often?

What types of liquids do you drink most? (coffee, tea, soda, fruit juice)

Do you exercise? What type? How often?

How do you relax?

Do you smoke, drink or use drugs? What type? How often?

By checking this box, I'm indicating that I've read, understood and accept the terms specified for this Life-Style Change consultation service.


	Home	About Us	Policies

Life-Style Change Consultation Questionnaire

Home

About Us

Policies