Adult health questionnaire
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ADULT HEALTH QUESTIONNAIRE Please complete this questionnaire as thoroughly as possible. Some of the questions answers are important. As it will help me to better understand the health issues that you are experiencing. All information that you provide will remain strictly confidential at all times, unless otherwise directed by yourself. Full name……………………………….................... Date of Birth………………… Address………………………………............................................................................. .......................................................................................Postcode……………………… Telephone:- Home………………………….. Mobile………………………………... Email Address………………………………................................................................. Gender:- Male Female Transgender Other………………………………....... Approx Height……………….. Approx Weight……………….. G.P’s name & address………………………………...................................................... ………………………………..........................................Tel.no……………………….. Are you taking any medication? (Prescribed and Complimentary) Yes No Please list on the chart below. (continue on reverse side of form in need more room) Name of medication Dose Frequency -1- Date Started Do you have any allergies? Yes No (if yes, please state) ………………………………............................................................................................... ………………………………............................................................................................... Do you have any conditions that could cause you to become poorly quickly? Yes No (if yes, please state what)……………………………................................... Who would you like me to contact in case of emergency? Name……………………………….................. Number(s)…………………………… Do you carry emergency medication? Yes No (if yes, please state) ………………………………............................................................................................... Is there a possibility you could be pregnant? Yes No (if yes, how many weeks)……………………… LIFE STYLE DETAILS Current Occupation………………………………......................................................... Previous Occupation(s)……………………………....................................................... ………………………………........................................................................................ What (if any) exercise or physically activity do you do?…………………………….... ………………………………........................................................................................ ………………………………........................................................................................ Interests/Hobbies………………………………............................................................ Do you smoke? Yes No (if yes please state daily amount)………………………. What is your daily fluid intake of:- Water……………….. Coffee…………………… Tea………………… Alcohol(units per week)………. Other………………………. What does your diet mainly consist of?…………………………….............................. ………………………………......................................................................................... How would you describe your sleep patterns? (sound sleeper, amount of hrs, disturbed)…………………………….................................................................................. Do you snore/grind teeth/get up regularly to go toilet? Yes No (if yes, please state)…………………………….......................................................................................... How would you score your stress levels - (please circle) At home - not stressed 0 1 2 3 4 5 6 7 8 9 10 + very stressed At work - not stressed 0 1 2 3 4 5 6 7 8 9 10 + very stressed Any other relevant information regarding your lifestyle………………………………. ……………………………….......................................................................................... .......................................................................................................................................... -2- YOUR PHYSICAL HEALTH Do you have any relevant family history? Yes No (if yes, please state) ………………………………............................................................................................... ......................................................................................................................................... What was your childhood health like?……………………………................................. ……………………………….......................................................................................... Your past medical history. (Please inc. any breaks/fractures/dislocations, plates or pins, replacements, pacemaker, stents, surgery, whiplash, head trauma or X-rays, Usounds, CAT scan, MRI)……………………………................................................... ……………........................................................................................................................ .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Have you had any dental work/surgery? Yes No (if yes, please state) ……………………………….......................................................................................... ……………………………….......................................................................................... Have you had ANY implants in your body? Yes No (if yes, please state where abouts on your body) ………………………………......................................................... ………………………………....................................................................................... Have you had any form of cosmetic surgery/botox/liposuction, etc? Yes No (if yes, please state where abouts on your body)……………………………............... ……………………………….......................................................................................... .......................................................................................................................................... Have you had any past pregnancies? Yes No (if yes, how many and were there any problems?)…………………………......................................................................... ……………………………….......................................................................................... .......................................................................................................................................... -3- Do you or have you ever suffered from the following complaints? Heart problems Yes No Fertility problems Yes No High/Low Blood pressure Yes No Gyneacological problems Yes No Blood related problems Yes No Prostate problems Yes No Poor circulation Yes No Back problems Yes No Loss of feeling Yes No Lung problems Yes No Varicose veins Yes No Asthma Yes No Diabetes Yes No COPD Yes No Pancreas problems Yes No Headaches/Migraines Yes No Liver problems Yes No Epilepsy Yes No Spleen problems Yes No Stress Yes No Gall Bladder problems Yes No Anxiety Yes No Stomach/Digestive problems Yes No Palpitations Yes No Bowel problems Yes No Panic Attacks Yes No Constipation Yes No Depression Yes No Diarrhea Yes No Mental Health Issues Yes No Kidney problems Yes No Cancers Yes No IBS Yes No Re-occurring infections Yes No Continence problems Yes No Undiagnosed lumps/bumps Yes No Lymphatic problems Yes No Undiagnosed areas of pain Yes No Water retention Yes No Foggy Head Yes No Swollen limbs Yes No Lethargy/Chronic fatigue Yes No Skin problems Yes No Osteoporosis Yes No -acne Yes No Rheumatic pain Yes No -itchy skin Yes No Osteo-arthritis Yes No -psoriasis/eczema Yes No Stiff or painful joints Yes No Hormonal Problems Yes No Menopause Yes No PMS Yes No Period problems Yes No Any problems not mentioned above? Yes No If you have answered yes to any of the above. Please give details…………………… ……………………………….......................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... -4- To help you get the most out of your Bowen treatment and ensure that it is tailored for you as accurately as possible, please answer the following questions as accurately and honestly as possible. Thank you. Are you currently being treated by any other therapist for any other problem? Yes No (if yes, please state therapy and problem)……………………………...... ……………………………….......................................................................................... ……………………………….......................................................................................... Your health complaints in order of significance to you. Severe Moderate Slight 1. ______________________________________________ 2. ______________________________________________ 3. ______________________________________________ How do these complaints impact on your daily life? eg mobility, home/work/family life, driving, exercise, general well being……………………………….............................. ………………………………............................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... What treatments have you tried for these complaints & what were the results? ……………………………….......................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Have you had to refrain from doing things you enjoy as a result of your complaint? Yes No (if yes, please state)……………………………......................................... ……………………………….......................................................................................... .......................................................................................................................................... PAIN CHART On the following page please use the diagrams to clearly mark any areas of pain or surgical scars. Please place an arrow beside each area of pain, (if more than one) rating the pain on a scale of 1 - 10 with 10 being the highest level of pain. After rating the pain please use one of the following words to describe the pain Sharp, stabbing, burning, fixed, travelling, ache, tingling, pins & needles, throbbing, pulsating, cramping or spasmodic. -5- Does the following lesson the pain:- Pressure Cold Heat Rest Exercise Elevation Other_____________________________________________________ Does the following make the pain worse:- Pressure Cold Heat Rest Exercise Elevation Other___________________________________________ How long does the pain last?______________________________________________ What has lead you to try Bowen therapy?……………………………............................ ……………………………….......................................................................................... Have you ever had a Bowen treatment before? Yes No How did you hear about Get going with Bowen?……………………………................. -6- Do I have permission to write to your Doctor and inform them that you are receiving treatment from Get Going with Bowen? Yes No I, hereby declare, that all the information I have given is true to the very best of my knowledge. However, should any circumstances change regarding my health, I will inform you at my next visit. I confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed without permission from my own Doctor or Consultant. Signed……………………………….......................................................................... Print………………………………............................................................................. Date……………………………….................... NB. The Bowen Fascial Release Technique is not intended as a substitution for medical advice or treatment. If you have any concerns regarding your health or condition pleas consult your G.P for advice. -7-
