Initial Interview Questionnaire 

Name *
Name
Address*
Address*
Best Phone Number* *
Best Phone Number*
Date Of Birth *
Date Of Birth
Gender *
Children *
HEALTH
Do you sleep well?
Do you drink caffeinated drinks? *
Do you smoke?
Are you or have you been exposed to second hand smoke? *
Do you drink alcohol? *
Do you drink soda? (diet or regular) *
Are you currently under a practitioners care for a specific health issue? *
Do you crave sugar? *
Do you crave salt? *
Do you feel any of the following after meals? *
Do you experience constipation or diarrhea? *
Do you feel excessively hungry or have a poor appetite? *
Family Health History
Do you have any of the following conditions in your family? Please check all that apply *
(i.e. IBS, crohn's, specific type of cancer)
For Women Only
Menstrual Cycle
Are your periods regular? *
Do you experience PMS (i.e bloating, irritable, crave foods, painful periods)
Pregnancy
Have you been or are you currently pregnant? *
History of miscarriages or abortions? *
Did you receive antibiotics during labor?
Peri-Menopause / Menopause
Are you peri-menopausal? *
Are you menopausal? *
Miscellaneous
Do you enjoy daily activities
Do you feel apathetic or complacent towards previously enjoyed sports, hobbies, games, or activities?
Do you feel your libido is adequate?
Would you like to discuss any women's health issues specifically?
For Men Only
Do you wake up in the night to urinate?
Do you have any difficulty/pain with urination?
Do you have a diminished flow?
Do you enjoy daily activities
Checkbox 30
Do you feel apathetic or complacent towards previously enjoyed sports, hobbies, games, or activities?
Do you feel your libido is adequate?
Do you feel less assertive in daily life than previously?
Would you like to discuss any men's health issues specifically?