Health & Lifestyle Questionnaire
Name: _________________________________
Date: ________________
Age: ___________________Date of Birth: _____________________________
Preferred Phone Number: ____________________________________ Cell/Land
Email: ___________________________________________________
Is it OK for this office to contact you by text / email / leave voice mail? (circle all that apply)
Address: _________________________________________________
City: __________________________ State: ____________ Zip: __________
How did you hear about Luminous Health? ______________________________________________________
_________________________________________________________________________________________
I understand that wellness services are provided for enhancement of my general health. I understand the
services are not treatment for medical conditions or injuries. I understand the services in no way take the place
of a primary doctor's care and I will seek proper medical care if it is indicated. The information provided is
understood to be educational and to be used at my own discretion. I understand the services provided are for
wellness promotion and there are no guarantees regarding specific goals and outcomes.
I authorize Luminous Health to release any medical or other information about me to referring providers, as
well as my family, referral and/or company physician. I also consent for my information to be shared with Dr.
Becca Wiley, Working on Wellness, in the interest of pharmaceutical and wellness consultation.
Signature ______________________________________________ Date_____________________________
1
Health & Lifestyle Questionnaire
Name: _________________________________
Major Health Issues (Please List):
Date: ________________
For Office Use Only:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
ZRT
__________________________
__________________________
_____Saliva________________
__________________________
__________________________
_____Blood Spot___________
Date Given:
_____Combo Kit____________
Chief concerns or health related goals:
_____Urine Kit_____________
__________________________
__________________________
_____Comp.Thyroid_________
__________________________
__________________________
__________________________
__________________________
BH
__________________________
__________________________
_____ARK 205_____________
__________________________
__________________________
_____ARK 201________
_____ARK 201 + Mel_______
Current Physician(s):
__________________________
__________________________
__________________________
__________________________
_____Muc.Bar 304B_________
Genova
Personal History of Cancer:
Family History:
_____2200_________________
Ovarian: ___________
Ovarian: ____________
Uterine: ___________
Uterine: ____________
Other
Breast: ____________
Breast:
____________
_________________________
Other: ____________
Other:
____________
Other health issues of concern: (check all that apply)
High Blood Pressure: _____ (medication?)_________________
High Cholesteral: ____ (medication?) ____________________
Low (abnormal) Thyroid: _____ (medication?) _____________
Seasonal allergies: _____ (medication?) _____________
2
Health & Lifestyle Questionnaire
Name: _________________________________
Date: ________________
For Office Use Only:
For Women Only:
Birth Control: Tubal Ligation: ______
Hysterectomy: ______
Vasectomy: ______
Other: _______Pap smear:
(Date) _________________
Mammogram: (Date) ___________________________
Menopause: Y____N ____Unsure____When: (Date/Age) ___________
How (Natural or Surgical): __________________
Current medications for menopausal symptoms:
Medication:
Dosage:
Length of Time Taken:
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
Past medications for menopausal symptoms:
Medication:
Dosage:
Length of Time Taken:
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
For Men Only:
Prostate exam: (last date) ________________________________
PSA results: ______________________________
Current medications (i.e. HRT, Testosterone):
Medication:
Dosage:
Length of Time Taken:
_____________________
_________
_________________
_____________________
_________
_________________
Past medications (i.e. HRT, Testosterone):
Medication:
Dosage:
Length of Time Taken:
_____________________
_________
_________________
_____________________
_________
_________________
3
Health & Lifestyle Questionnaire
Name: _________________________________
Date: ________________
For Office Use Only:
Lifestyle
Diet: Weight:
Current _______
Lowest adult weight _______
Highest adult weight _______
Caffeine usage: Amount per day________
Circle all that apply: coffee, tea, diet soda, soda
Sugar intake: Amount per day________
Simple carb intake:
Amount per day________
Circle all that apply: white flour, bread, pasta, fruit
Sweetener usage: Amount per day ________
Food allergies/known: Type________
Daily water intake: Amount per day ________
Alcohol use (including beer & wine): Type________
Drinks per day ________Drinks per week ________
Are you on any special diets? ______Y ______N
If yes, please specify ______________________________
Tobacco: Do you currently use tobacco? _____Y _____N
If yes, what type? __________________ Amount per day________
How many hours per week do you watch TV? ________________
How many hours per week do you work/play on the computer?
_____________________________
4
Health & Lifestyle Questionnaire
Name: _________________________________
Date: ________________
For Office Use Only:
Sleep Patterns:
Bed Time: _________________ Wake Time: ________________
Sleep Issues: ______________________________________________
__________________________________________________________
Bedtime Routine: ___________________________________________
__________________________________________________________
Medications:
Please list any drug allergies: _________________________________
_________________________________________________________
Current general medications:
Medication:
Dosage:
Directions:
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
Supplements/Vitamins/Herbals:
Product/Brand
Dosage:
Length of Time Taken:
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
_____________________
_________
_________________
5
Health & Lifestyle Questionnaire
Name: _________________________________
Date: ________________
For Office Use Only:
Wellness and Exercise:
Yoga practice:
__________________________________________________________
__________________________________________________________
Exercise regimen:
__________________________________________________________
__________________________________________________________
Circle any of the following that you have had in the past or have
now:
Changes in breasts
fibrocystic disease
asthma
fungal lung infections
tuberculosis
COPD
irregular heart beat
high blood pressure
chest pains
high cholesterol
nausea
vomiting
abdominal pain
diarrhea
excessive gas
constipation
changes in appetite
frequent urinary infections
irregular periods
change in libido
fertitlity issues
joint pains
fibromyalgia
anemia
changes in hair
changes in nails
goiter
low thyroid
high thyroid
swelling in hands/feet
6