Daily Life-Style Evaluation Form
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(Print and fill in this form and bring it to your consultation, also attach a recent photograph of yourself)
NAME________________________________________________________
DATE__________________ D.O.B: ___________________(compulsory)
TEL_________________________MOBILE__________________________
E-MAIL_______________________OCCUPATION:____________________
ADDRESS____________________________________________________
MARITAL STATUS______________________
HEIGHT_____________________(compulsory)
WEIGHT____________________ (compulsory)
SEX________________________ (compulsory)
PRESENT MEDICAL HISTORY / MEDICAL TEST REPORTS / X-RAY ETC
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__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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MEDICATION, PRESENT:
__________________________________________________________
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Patient Information Form
The following questions will greatly assist in our being able to correctly identify your imbalances. Please circle the option that best describes you.
1. Bowel Movements
Do you move your bowels daily? Yes No
Is your bowel movement roughly at the same time of day? Yes No
When? Morning Afternoon Evening
Would you say you are constipated? Yes No
Do you have Diarrhea Yes No
Do your stools: float sink
Have you observed the color?
Could you describe the odor?
2. Appetite
How many meals do you have daily 1 2 3 4
Which is your main meal?
When do you get hungry?
Do you eat most meals at: home out
What are your favorite foods?
What time do you eat your last meal (usually)?
3. Sleep
How many hours sleep do you get a night?
Do you dream have nightmares
How would you say you sleep?
…………………………………………………………………………………..
Do you wake in the night to go to the toilet? Yes No
Do you wake up feeling - fresh tired still sleepy
What time do you go to sleep?
4.Periods/ reproductive information
Is your monthly period regular? Yes No
Do you suffer any P.M.S? ……………………………………………………………..
If so briefly state how this affects you… …………………………………………….
Are you sexually active Yes No
5. Exercise
What kind of exercise or games do you participate in?
………………………………………………………………………………………
How often do you exercise
………………………………………………………………………………………
6. Emotional state
What words would you use to describe your current state of mind?
What words would you use to describe your emotions?
7. Fluid intake
How many glasses of water do you drink in the day?
Do you wake in the night to drink water? Yes No
8. Physical Pains
Are you suffering form aches or pains in any part of your anatomy? If so state where
9. Nature of work
How active are in your job? Describe briefly if you interact with others if you sit or are on the move all day etc…
10. Travel
Do you have to travel as part of your work Yes No Often
Do you travel a lot for holidays Yes No