Serving Simcoe County since 1998! The Following is a questionnaire I need you to fill out. It will aid me in determining where your diet lacks and give me a better idea as to how to proceed with your therapy. The cost of analysis is listed on the rates page (hit back to return here) Please be assured that all information collected here is exclusively for my use and will not be shared with any one. Thank you, Lisa

 

Please identify yourself Name Email City State/Prov. Phone number Gender Female Male             Age Blood type O A B AB   Rh + - Please rate all of your symptoms NeverAlwaysSometimes Fatigue NeverAlwaysSometimes Irritable Bowel (e.g., diarrhea, constipation, etc.) NeverAlwaysSometimes Sleep disorder (or sleep that is not refreshing ) NeverAlwaysSometimes Chronic headaches (tension-type or migraines) NeverAlwaysSometimes Jaw pain (including TMJ dysfunction) NeverAlwaysSometimes Cognitive or memory impairment NeverAlwaysSometimes Post-exertional malaise and muscle pain NeverAlwaysSometimes Morning stiffness (waking up stiff and achy) NeverAlwaysSometimes Menstrual cramping NeverAlwaysSometimes Numbness and tingling sensations NeverAlwaysSometimes Dizziness or lightheadedness NeverAlwaysSometimes Food, skin and chemical sensitivities NeverAlwaysSometimes Chest pain / angina NeverAlwaysSometimes Muscle jerks ( crazy legs, cramps, charlie horses ) NeverAlwaysSometimes Irritable bladder ( frequent or urgent urination ) NeverAlwaysSometimes Swollen extremities ( ankles, feet, hands wrists ) NeverAlwaysSometimes Prescription changes ( glasses, meds ) NeverAlwaysSometimes Anxiety attacks Anything else? Check each of the Diseases you have been diagnosed with AIDS Allergies Arthritis Attention deficit Bipolar / manic depression Cancer Carpal tunnel Chronic fatigue syndrome Crohn's Diabetes Endometriosis Fibromyalgia Hepatitis Impetigo M S Tennis elbow, tendonitis Other Other Please list any operations or surgeries you have had, and the year 1 Year 2 Year 3 Year 4 Year 5 Year Please list any medication you are currently on Also list amounts per day and how long you have taken this med  1  2  3  4  5  6  7  8  9 10 If you are taking more then the 10 listed above   email me  the additional meds NOW include any extra surgeries as well Let's explore your stress loads Exercise is a positive stress Do you work out regularly? Yes No If yes, please tell a little of what you do weekly: Have any of these major stresses happened in the past year? Check means yes Death of Spouse or Child Divorce or separation Moved after many years Changed jobs after many years Death of personal pet or friend Unemployed Major fire or burglary Mugged or raped Other Which of these constant stresses are you experiencing? My kids are teens My baby is under an year Empty nest syndrome I hate my job Too much overtime In-laws don't approve of me Marriage problems Single or no friends I smoke I worry about my health Other Do you have any beliefs I should know about? Religion: Other Beliefs: Anything else you would like to add, to help me understand your health problems? Let's have a look at your diet List your food allergies here On a daily average: How many servings do you take of each food group? Grains: Veggies: Meats: Dairy: Fats: If dieting: calories / day Specialized diet: How many meals a day do you eat? 1 2 3 4 More Fluids: Total amount mL oz Types: Tea Pop Coffee Milk Water Juice other (check all that apply, does not include alcohol) How much sugar do you put in your tea or coffee? spoons each cup Do you crave: Fat Sugar Salt None of these Alcohol: Total amount Types: Wine Beer Liquor other Tell me about your snacking habits, what is most popular, time of day and how soon before bed? One last question How would you like to make payment? (accepted in office or by mail only) Cash Money order (the following accepted online through paypal.com) Credit/bank card Cheque Thank you. Your information will be held in strict confidence. Lisa Stel - BSc, CHt A Healing Advantage Close window when done to return to main website If you still have questions feel free to contact us. Here's to living life through knowledge and self-empowerment BSc, CHt Mission Hypnosis Articles Regressions Spirit Reiki Nutrition Rates Contact Tell a Friend!

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