Makeripples

Below is the health evaluation I use for the manual assessment (non-computer) in my office. I ask the client these questions and fill in the blanks. This allows them to think about the answers. It also allows me to observe their feelings about different issues. I find that this discussion time relaxes the client, and allows them to see how much I truly care. Feel free to use it in your office with my blessing, however realize that different client react to these questions in many different ways. Often times the client will laugh and relax but frequently they cry when they see that you care.

Health History

NAME_________________________________________ PHONE #_____________ DATE_________ ADDRESS__________________________________________________________________________

AGE ______ SEX_____ HEIGHT_______ WEIGHT______ OCCUPATION_____________________

DO YOU LIKE YOUR JOB?_____________________________________________________________

ARE YOU INVOLVED IN A RELATIONSHIP?______________________________________________

WHAT ARE THE AGES OF YOUR CHILDREN?_____________________________________________

DESCRIBE YOUR NORMAL DAYS EATING TO ME: Breakfast_____________________________________________________________________________ Lunch________________________________________________________________________________ Dinner_______________________________________________________________________________ Snacks_______________________________________________________________________________

PLEASE DESCRIBE YOUR NORMAL DAYS FLUID INTAKE TO ME:

Water___________________________________ Alcohol_______________________________________ Coffee/Tea_______________________________ Soda_________________________________________ Juice____________________________________ Other________________________________________

WHAT TYPE OF WATER DO YOU DRINK?_______________________________________________

HOW MUCH SLEEP DO YOU GET ON THE AVERAGE? _______ IS IT SOUND ?________________

DO YOU WAKE TO VOID ? ________ DO YOU HAVE URINARY URGENCY? _________________

DESCRIBE YOUR NORMAL BOWEL ROUTINE TO ME: ____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

DESCRIBE YOUR ENERGY LEVEL TO ME:________________________________________________ ____________________________________________________________________________________

DO YOU FEEL STRESSED? __________________

WHAT DO YOU DO WHEN YOU'RE STRESSED? ___________________________________________ _____________________________________________________________________________________

DO YOU CURRENTLY SEE A MEDICAL DOCTOR FOR ANY REASON?_______________________

SURGERIES___________________________________________________________________________ _____________________________________________________________________________________

ARE YOU CURRENTLY TAKING ANY MEDICINES? (Please include birth control pills) ______________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

PLEASE LIST ANY SUPPLEMENTS YOU ARE NOW TAKING? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

DID YOU TAKE THEM TODAY?_________________________________________________________

WHAT TYPES OF EXERCISE DO YOU DO? _____________________________________________________________________________________

DO YOU CURRENTLY HAVE PROBLEMS WITH ANY OF THE FOLLOWING:

DO YOU HAVE FOOD CRAVINGS SUCH AS CHOCOLATE, PEANUT BUTTER, BREADS, ALCOHOL OR SWEETS? _________________________________________________________________________

WHAT IS YOUR MAIN CONCERN THAT BROUGHT YOU HERE TODAY? _____________________ _____________________________________________________________________________________

IS THERE ANYTHING YOU HAVEN’T TOLD ME THAT YOU THINK I SHOULD KNOW? ________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________