Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.
Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.
BIOGRAPHICAL DATA: INITIAL CONSULTATION QUESTIONARE (INCLUDING SKYPE)
Clients Name: ________________________________________________________ D.O.B: ____/____/____
Address: _________________________________________________________________________________
_____________________________
Phone: _________________________________________________
Alt Phone: ______________________________ Email: ___________________________________________
Age:______ Gender:_____________________________________
Relationship Status:___________________________ Children (Ages): _______________________________
Occupation:_________________________________ Since when: __________________________________
Emergency Contact Person: __________________
Phone: ______________________________________
Relation to you: ____________________________
General Practitioner: ________________________
Phone: ______________________________________
Religion/Cultural Considerations: ______________________________________________________________
PRESENTING COMPLAINT (including nature, onset, progression, perceived cause, Influencing factors,
associated symptoms, Aggravated / alleviated by, Pain scale 1-10, Prevention of activities, )
PRESENT HEALTH CONCERNS
Time of first onset
Circumstances
Progression
Precipitating factors
Aggravating factors
Relieving factors
Associated symptoms
Previous diagnosis / treatments Please include any significant lab results or imaging
Medical supervision
List all medications
Client goals
Page 1 of 6
Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.
Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.
BODY SYSTEMS HEALTH PROFILE
G.I. / DIGESTIVE PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION. LEAVE
BLANK IF NOT APPLICABLE
____WT CHANGE ____DENTAL PROBLEMS ____NAUSEA ____INDIGESTION ____DYSPHAGIA (DIFFICULTY SWALLOWING)
____VOMITING
____ HAEMATEMIS (VOMITING UP BLOOD) ____ ACID REFLUX ____ DIARRHOEA ____ IRRITABLE BOWEL SYNDROME
____ ANOREXIA NERVOSA ____ DIVERTICULITIS ____ MOUTH ULCERS ____ BAD BREATH ____ DUODENAL ULCER ____
PARASITES
____ BLOATING ____ FLATULENCE ____ POLYPS ____ BULIMIA ____ GALLSTONES ____ RECEDING GUMS ____
CONSTIPATION
____ HAEMORRHOIDS ____ STOMACH ULCER ____ CROHN’S DISEASE ____ HISTORY OF HEPATITIS ____ ULCERATIVE
COLITIS
____ OFTEN FORGET TO EAT ____STRONG APPETITE, EAT REGULARLY ____ CAN SKIP MEALS EASILY ____ ANXIOUS OR
FAINT IF SKIP A MEAL ____ GET IRRITABLE IF SKIP A MEAL ____ PREFER TO EAT 2-3 X A DAY ____ BLOATED/HEAVY AFTER
EATING
____ HEARTBURN/ACIDITY AFTER EATING ____ SLEEPY/HEAVY AFTER EATING
____OTHER:____________________________________________
____ ABDOMINAL PAIN ____ LOOSE STOOL ____PALE GRAY STOOL
____ BLOOD IN STOOL ____ FOOD PARTICLES IN STOOL ____ PENCIL THIN STOOL
____ MUCUS IN STOOL ____ CHANGES IN BOWEL HABITS ____ STOOL THAT FLOATS ____ PAINFUL DEFECATION
____ QUICK DEFECATION AFTER EATING ____ OTHER: ______________
HOW FREQUENTLY DO YOU HAVE A BOWEL MOVEMENT?
ARE THEY GENERALLY ON THE HARDER OR SOFTER SIDE?
URINARY SYSTEM PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION. LEAVE
BLANK IF NOT APPLICABLE
____ BLADDER INFECTIONS ____PAINFUL URINATION ____ CRAVINGS FOR SALT
____ KIDNEY STONES ____ LOWER BACK PAIN ____ EXCESSIVE FEAR/FEARLESSNESS
____ WATER RETENTION/OEDEMA ____ DARK CIRCLES UNDER EYES ____ FREQUENT URGE TO URINATE
____ DRIBBLING/INCONTINENCE ____GOUT ____ WAKE UP AT NIGHT TO URINATE
____ EXCESSIVE URINATION ____FREQUENT THIRST ____ INCOMPLETE EMPTYING OF BLADDER ____ DIFFICULT STARTING
____ LOIN PAIN ____ HAEMATURIA (BLOOD IN URINE) ____ POOR STREAM
IS YOUR URINE TYPICALLY DARK OR LIGHT OR CLEAR IN COLOUR?
REPRODUCTIVE FOR WOMEN ONLY
GYN/REPRO
REPRODUCTIVE WOMEN PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION.
LEAVE BLANK IF NOT APPLICABLE
PREGNANCIES (DATES): __________________________________________________________________________
MISCARRIAGES (DATES): __________________________ ABORTIONS (DATES): _______________________________
CONTRACEPTIVE USE: LIST TYPE AND DURATION OF USE: ___________________________________________________
___________________________________________________________________________________________
SEXUALLY TRANSMITTED DISEASE; LIST TYPE IF KNOWN: ____________________________________________________
HYSTERECTOMY (DATE): _______________________________________REASON:____________________________
____ UTERINE FIBROIDS ____ OVARIAN CYSTS ____ ENDOMETRIOSIS
____ PELVIC INFLAMMATORY DISEASE ____ CERVICAL DYSPLASIA ____ INFERTILITY
____ VAGINAL ITCHING/DISCHARGE ____ PAINFUL INTERCOURSE ____ VAGINAL INFECTION
____ BREAST PAIN ____ FIBROCYSTIC BREASTS ____ LACK OF SEX DRIVE
MENSTRUATING WOMEN:
____ ABSENCE OF MENSTRUAL CYCLES ____ IRREGULAR CYCLES ____BLEEDING BETWEEN CYCLES
____ DRAMATIC MOOD SWINGS ____ BREAST TENDERNESS ____ CRAVE SUGAR BEFORE MENSES
____ MENSES SLOW TO START ____ MENSES ALWAYS LENGTHY ____HEAVY BLEEDING
____ PAINFUL MENSTRUAL CRAMPS ____ CLOTS IN MENSTRUAL BLOOD ____ ANAEMIA
____ MENARCHE (AGE OF FIRST MENSTRUATION)
PLEASE ELABORATE ON ANY INCONSISTENCIES OR CONCERNS YOU HAVE ABOUT YOUR CYCLE:
_
_____________________________________________________________________
Page 2 of 6
Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.
Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.
MENOPAUSAL WOMEN: PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION.
LEAVE BLANK IF NOT APPLICABLE
____ DRY VAGINAL LINING ____ HORMONE REPLACEMENT THERAPY ____ SORE MUSCLES
____ HOT FLASHES ____ MOOD SWINGS ____ NIGHT SWEATS
____ OSTEOPOROSIS ____ ESTROGEN REPLACEMENT THERAPY OTHER: __________________
______________________________________________________________________
_____________________________________________________________________________________________________________
REPRODUCTIVE MEN: PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION.
LEAVE BLANK IF NOT APPLICABLE
SEXUALLY TRANSMITTED DISEASE; LIST TYPE IF KNOWN: ___________________________________________________
____ BENIGN PROSTATIC HYPERTROPHY ____ IMPOTENCE ____ PAINFUL EJACULATION
____ LOW SEX DRIVE ____ LOW SPERM COUNT ____ LOW SPERM MOTILITY
____PREMATURE EJACULATION ____ PROSTATITIS ____ DIFFICULTY WITH URINATION
____ OTHER:
IMMUNE / LYMPHATIC SYSTEM PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST
CONDITION. LEAVE BLANK IF NOT APPLICABLE
____ARTHRITIS (RHEUMATISM) ____ AUTOIMMUNE DISORDERS ____FIBROMYALGIA
____CHRONIC FATIGUE ____ NEURALGIA ____FREQUENT COLDS/INFECTIONS
____ LOW-GRADE FEVER ____ LOW WHITE BLOOD CELL COUNT ____ INJURIES HEAL SLOWLY ____ SWOLLEN LYMPH
GLANDS ____ MONONUCLEOSIS ____ LYME DISEASE ____ LYMPHATIC CONGESTION ____ FEEL “UNCLEAN” ____
OTHER: ________________
ENDOCRINE SYSTEM PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION.
LEAVE BLANK IF NOT APPLICABLE
____ ADRENAL FATIGUE ____ HYPOGLYCAEMIA ____ ELEVATED BLOOD SUGAR
____ DIABETES (TYPE I OR II?) ____ METABOLIC SYNDROME ____ HYPOTHYROID
____ HYPERTHYROID ____ OVERWEIGHT, DIFFICULTY LOOSING ____ DIFFICULTY GAINING WEIGHT
____ PITUITARY ____ PINEAL ____
OTHER: _______________
NERVOUS SYSTEM PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION. LEAVE
BLANK IF NOT APPLICABLE
____ SLEEP DISTURBANCE ____ DIZZINESS/VERTIGO ____ FAINTING/FITS ____ WEAKNESS ____ ADD/ADHD
____ HERPES OR SHINGLES OUTBREAKS ____ PANIC ATTACKS ____ ANXIETY ____ DEPRESSION ____OBSESSIVE
BEHAVIOUR
____ IRRITABILITY ____OVERWHELM ____ NUMBNESS ____ MEMORY LOSS OR CHANGES ____ MENTAL FOG ____ STRESS
____ HEADACHES ____ MIGRAINES ____ INSOMNIA ______________ DREAMS
IF YOU GET HEADACHES, CAN YOU DESCRIBE THE PAIN, LOCATION & TRIGGERS?
WHICH EMOTIONS DO YOU EXPERIENCE MOST FREQUENTLY? PLEASE USE O=OFTEN, S=SOMETIMES, N=NEVER
____ ANGER ____ JOY ____SADNESS ____GRIEF ____WORRY
____ IRRITABILITY ____ FEAR ____ MELANCHOLY ____ RESTLESSNESS ____ LETHARGY
____ FAILING VISION ____ HEARING LOSS ____ TINNITUS/RINGING IN EARS
Page 3 of 6
Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.
Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.
HEART & CVS PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION. LEAVE
BLANK IF NOT APPLICABLE
____CHEST PAIN ____ SOBOE (SHORTNESS OF BREATH ON EXERTION) ____ ORTHOPNEA (HAVING TO SIT OR STAND TO
BREATHE PROPERLY)
____ COLD EXTREMITIES (HANDS AND/OR FEET) ____ HIGH BLOOD PRESSURE ____ LOW BLOOD PRESSURE ____ HIGH
CHOLESTEROL
____PALPITATIONS ____ ARTERIOSCLEROSIS ____ ATHEROSCLEROSIS ____ HISTORY OF HEART ATTACK ____ HISTORY OF
STOKE
____ CONGESTIVE HEART FAILURE ____ HANDS COLD, CLAMMY OR DRY ____ HANDS WARM, SWEATY ____ VARICOSE
VEINS
____ SWELLING IN ANKLES/JOINTS ____ OTHER: ____________________________________________
RESPIRATORY PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION. LEAVE
BLANK IF NOT APPLICABLE
____ EAR ACHES ____ EAR INFECTIONS ____ SORE GUMS
____ SORE THROAT ____ LARYNGITIS ____ FREQUENT NOSE BLEEDS
____ FREQUENT STUFFY NOSE ____ HAYFEVER ____ TONSILS
____ EXCESSIVE SALIVA ____ DIFFICULTY SWALLOWING ____ OTHER: ____________________
____HAEMOPTYSIS (COUGHING UP BLOOD)
____ ALLERGIES ____ DIFFICULTY BREATHING ____WHEEZING
____ ASTHMA ____ SHORTNESS OF BREATH ____ BRONCHITIS
____ COUGH ____ FLUID IN LUNGS ____ PLEURISY
____ POSTNASAL DRIP ____RECURRENT INFLUENZA ____ COLD
____ SINUSITIS ____ RUNNY NOSE ____ TUBERCULOSIS
____ STUFFY NOSE ____ CLEAR, THIN MUCUS ____ YELLOW/GREEN MUCUS
____ DRY, HARD MUCUS ____ EASY TO COUGH UP MUCUS ____ OTHER: ______________
MUSCULO-SKELETAL PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION.
LEAVE BLANK IF NOT APPLICABLE
____ JOINT SWELLING ____ ARTHRITIS (NOT RHEUMATOID) ____ MOBILITY RESTRICTION ____ SPRAINS
____ BACKACHE UPPER/LOWER PAIN ____BROKEN BONES ____ TENDONITIS ____ TORN LIGAMENTS ____ GOUT
____ STIFFNESS ____ BURSITIS ____ OTHER: ___________________
SKIN PLEASE RATE ITEMS AS 1= SOMETIMES 2= OFTEN 3= MAJOR CONCERN OR P = PAST CONDITION. LEAVE BLANK IF NOT
APPLICABLE
____ ACNE ____ EASILY SUNBURNED ____ MOLES
____ BOILS ____ ECZEMA AND DERMATITIS ____ RASHES
____ BLEED OR BRUISE EASILY ____ PSORIASIS ____ SLOW WOUND HEALING
____ DRY/ITCHY SCALP OR HAIR ____ RED, BURNING OR FLUSHED SKIN ____OILY, DAMP SCALP OR HAIR
____ FUNGAL INFECTIONS ____HERPES (COLD SORES)
____ OTHER:
Page 4 of 6
Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.
Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.
DIET
AM
MID AM
LUNCH
MID PM
DINNER
SUPPER
DRINKS
OIL USE
WHAT FOODS DO YOU CRAVE? _____________________________________________________________________
WHAT ARE YOUR FAVOURITE AND LEAST FAVOURITE FOODS?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________________________
DO YOU HAVE ANY KNOWN FOOD ALLERGIES? NO __ YES __ LIST:
___________________________________________________________________________________________
___________________________________________________________________________________________
DO YOU CONSUME ANY OF THE FOLLOWING: PLEASE INDICATE: S= SOMETIMES, O= OFTEN, N=NEVER
_____ SOY PRODUCTS _____ MEAT _____ FISH _____EGGS _____DAIRY
_____ BEER _____ WINE _____ COFFEE _____ SODA _____ TEA _____ SUGAR _____ CANDY _____ BAKED GOODS _____
PROCESSED FOODS _____ FAST FOOD
_____ WHITE BREAD _____ WHOLE GRAIN BREAD _____ COLD CEREAL _____ WHOLE GRAINS OR QUINOA
_____ RAW VEGGIES _____ COOKED VEGGIES _____ RAW FRUIT _____ DRIED OR COOKED FRUIT
_____ FRIED FOODS _____BUTTER _____ MARGARINE OR EARTH BALANCE
_____ CANOLA, SAFFLOWER, SUNFLOWER, SOY OR CORN OILS _____ OLIVE, COCONUT, SESAME OR PALM OILS
_____ ORGANIC PRODUCE, GRAINS ____ PASTURED/GRASS-FED EGGS, POULTRY, MEAT AND DAIRY
DO YOU OFTEN: CHECK ALL THAT APPLY
_____ EAT OUT MORE THAN ONCE A WEEK ____ COOK YOUR MEALS AT HOME
_____ EAT FROZEN/PACKAGED FOODS ____ COOK YOUR MEALS FROM SCRATCH
_____ FEEL RUSHED DURING YOUR MEALS ____ EAT WITHOUT DISTRACTIONS
_____ EAT WHILE STANDING, READING, WATCHING TV ____ EAT REGULARLY TIMED MEALS
_____ OVER EAT ____ EAT UNTIL SATIATED OR JUST UNDER
Page 5 of 6
Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.
Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.
CLIENT CONSENT
I, ____________________________________________________________________________________________(FULL NAME),
GIVE CONSENT FOR MY HEALTH INFORMATION TO BE DOCUMENTED AND APPROPRIATE PHYSICAL EXAMINATIONS AND
ASSESSMENTS TO BE PERFORMED. I UNDERSTAND THAT FOLLOWING THE CONSULTATION A TREATMENT PLAN WILL BE
CREATED FOR ME AFTER AGREEMENT BETWEEN MYSELF AND THE PRACTITIONER. I WILL GIVE THE PRACTITIONER ALL
PERSONAL INFORMATION NEEDED TO PERFORM A SAFE AND SUCCESSFUL TREATMENT.
I AM AWARE THAT BOTH PRACTITIONER AND I HAVE THE RIGHT TO STOP THE CONSULTATION PROCEDURE AND / OR
TREATMENT AT ANY TIME.
CLIENT SIGNATURE:___________________________________________ DATE:_______________________________
PRACTITIONER SIGNATURE:____________________________________________
Page 6 of 6