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Claudio Voarino - Clinical Nutrition and Herbalism Consultant - Dip. (C.N.C) Dip. (Cl. H.) Dip. (Med. H.) Dip. (H. Sc.) Cert. (F.H.)

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Questionnaire

This questionnaire is distributed to clients in order to create a health/lifestyle profile to assist in providing them the best consultation advice possible. This questionnaire can be printed directly from this page or can be downloaded and printed from a PDF file. All information gathered from this profile is held in the strictest confidence.
Download the PDF version of this questionnaire by CLICKING HERE (You may need to right-click and select "Save-As" depending on your browser software)

Client Questionnaire FORM A
*Client Details*
Name:	..............................................................
Postal Address:	.............................................................. .............................................................. .............................................................. ..............................................................

Date of Birth:	...... / ...... / ............
Gender:	Male ( ) Female ( )
Height:	..............................................................
Weight:	..............................................................

Occupation:	..............................................................

Hobbies:	.............................................................. .............................................................. .............................................................. ..............................................................

Marital Status:	..............................................................

*Questions about Client's health*
What is your blood pressure?	..............................................................
Do you have a high cholesterol level?	..............................................................
Do you have diabetes?	..............................................................
Do you have heart problems?	..............................................................
Do you have allergies?	..............................................................
Do you suffer from indigestion?	..............................................................
Is your hair falling out?	..............................................................
Do you have joint pains?	..............................................................
Do you suffer from headaches?	..............................................................
Do you have liver problems?	..............................................................
Do you suffer from constipation?	..............................................................
Do you have kidney problems?	..............................................................
Do you have menstrual problems?	..............................................................
Do you have muscle cramps?	..............................................................
Do your nails split?	..............................................................
Do you smoke?	..............................................................
Do you drink too much alcohol?	..............................................................
Are you a vegetarian or a vegan?	..............................................................
Do you regularly eat meat?	..............................................................
Do you regularly drink cows’ milk?	..............................................................
Do you drink Coca Cola /other soft-drinks?	..............................................................
Do you often eat sugary foods?	..............................................................
Do you have ulcers?	..............................................................
Do you wake up feeling tired?	..............................................................
Do you have sleeping problems?	..............................................................
Do you have prostate problems?	..............................................................
Do you suffer from any sexual disjunctions?	..............................................................
Do you have varicose veins?	..............................................................
Are you easily irritated?	..............................................................
Do you suffer from any kind of depression?	..............................................................
Do you often feel exhausted?	..............................................................
Does your back ache?	..............................................................
Are you an active or sedentary person?	..............................................................
How much water do you drink daily?	..............................................................
What does your daily diet consist of?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................

*Client's Medical History*
What are your present health complaints?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................
How long since you had your latest medical check-up?	..............................................................
Are you on medications?	..............................................................
Have you been on medications in the past two years?	..............................................................
If yes, which medications, and for what?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................
Which major diseases, if any, did you suffer from in the past 5 years?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................
Did you have any major surgical operation?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................
Have you lately been diagnosed with any degenerative illness?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................
If yes, which illness or illnesses?	.............................................................. .............................................................. .............................................................. .............................................................. .............................................................. ..............................................................

Page Date: 13/12/2011

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