Client Assessment Form

Name: *
E-mail Address: *
Address: *
Phone:
-
Age

If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply.

1. General fatigue or weakness
2. Difficulty losing weight
3. Frequent illness/infections
4. High stress Lifestyle
5. Smoking
6. Drinking more than 2 cups of coffee/day
7. Bad breath and/or body odour
8. Constipation
9. Bags under eyes
10. Crave sugars, bread, alcohol
11. Difficulty digesting certain foods
12. Have used antibiotics in past 10 years
13. Allergies
14. Poor concentration or memory
15. Belching or burping after meals
16. Skin/complexion problems
17. Frequent consumption of red meat)
18. Regular use of dairy products
19. Heavy alcohol consumption
20. Exposure to toxins/chemicals
21. Frequent mood swings
22. Depressed and/or irritable
23. Brittle fingernails
24. Dry, brittle hair, split ends
25. High fat/high cholesterol diet
26. Nervousness/anxiety/tension/worry
27. Insomnia/restless sleep
28. Low fibre diet
29. Muscle cramps
30. Sleepy when sitting up
31. Female: menstrual cramps
32. Bronchitis/asthma/pneumonia/emphysema
33. Cellulite
34. Cold hands and feet
35. Varicose veins
36. Feeling out of control
37. Food/chemical sensitivities
38. Frequent yeast/fungus problems
39. Bones break easily, osteoporosis
40. Too little exercise

(Check:  1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply.)

41. Excessive mucous
42. Short of breath climbing stairs
43. Tingling in lips, fingers, arms, legs
44. Chest pains
45. Very rapid or slow heart beat
46. Painful, hard or thin bowel movements
47. Alternating constipation/diarrhea
48. Recurrent bladder infections
49. Female: Menopause, hot flashes
50. Female: PMS
51. Difficult urination
52. Swollen glands, puffy throat
53. Lower abdominal pain
54. Frequent need to urinate
55. Joint pain
56. Sinus inflammation/discharge
57. Arthritis
58. Sudden weight gain/loss
59. Headaches/Migraines
60. Female: Taking birth control pills
61. Lower back pains
62. Dry, flaky skin
63. Drink less than 6 glasses of fluids/day
64. Water retention
65. Low sex drive
66. Feeling heavy/bloated after meals
67. Chronic cough
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