Health Questionnaire and Release Form
Please fill out the following questionnaire to the best of your ability.
Name: ___________________________________________ Birth Date: ____________________________
Address: ________________________________________________________________________________
Phone #: ____________________________ Email: _____________________________________________
Medical / Clinical History:
Are you currently or have you in the past 2 years been under the care of a health practitioner for any illness of
conditions? Y / N If yes please describe and note any prescription medications:
Do you currently have any illnesses or conditions, for which you are not seeing a health practitioner? Y / N
Are you Pregnant? Y / N
Nursing? Y / N
On birth control pills? Y / N
How often do you have a bowel movement?
Have you had any surgeries in the past 5 years? Y / N If yes, please state what type.
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425-830-4883
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Social History:
Do you have a support network? If so who?
Do you usually eat alone or with someone else?
Do you have enough money to buy the food you need and want?
Do you drink alcohol? Y / N If yes, how often and what types?
Do you use tobacco products? Y / N If yes, how often and what types?
Exercise habits: How often and what types of exercise do you do?
Diet History:
Have you experienced any weight loss or gain in the last 6 months? Y / N In the last year? Y / N
Pounds gained _________ or lost: _______ time frame: ____________
What is your current body weight: ______ What is your usual body weight: _____
Are you comfortable at your current body weight? Y / N If no, what is your desired weight and within how much time
do you want to achieve this?
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425-830-4883
erin@ezbalance.com
Instructions: Fill in only the circles which apply to you. 1 = mild symptoms, 2 = moderate symptoms (occurs several
times a month), 3 = severe symptoms (occurs several times a week)
1
2
3
Group 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Acid Foods Upset
Get chilled often
“lump” in throat
Dry mouth, eyes, nose
Pulse speeds after meal
Keyed up – fail to calm down
Cut heals slowly
Gag easily
Unable to relax; startles easily
Extremities cold, clammy
Strong light irritates
Urine amount reduced
Heart pounds after retiring
“Nervous” stomach
Appetite reduced
Cold sweats often
Fever easily raised
Neuralgia-like pains
Staring, blinks little
Sour stomach
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
1
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
2
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
3
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Group 2
Joint stiffness upon rising
Muscle-leg-toe cramps at night
“Butterfly” stomach, cramps
Eyes or nose watery
Eyes blink often
Eyelids swollen, puffy
Indigestion soon after meals
Always hungry, feels lightheaded
Digestion rapid
Vomiting frequent
Hoarseness in voice
Breathing irregular
Pulse slow; feels “irregular”
Gagging reflex slow
Difficulty swallowing
Alternating constipation & diarrhea
“Slow starter”
Get “chilled” infrequently
Perspire easily
Circulation poor, sensitive to cold
Subject to colds, asthma, bronchitis
1
2
3
Group 3
O
O
O
O
O
O
Eat when nervous
Excessive appetite
42
43
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44
45
46
47
48
49
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
50
51
52
O
O
O
O
O
O
O
O
O
53
54
55
O
O
O
O
O
O
O
O
O
Hungry between meals
Irritable before meals
Get “shaky” if hungry
Fatigue, eating relieves
“Lightheaded” if meals delayed
Heart palpitates if meals
missed/delayed
Afternoon headaches
Overeating sweets upsets
Awaken after few hours of sleep –
hard to fall asleep again
Crave candy/coffee in PM
Moods of depression
Craving of sweet snacks
1
2
3
Group 4
56
57
58
59
60
61
62
63
64
65
66
67
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
68
69
70
71
72
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Hands and feet go to sleep easily
Sigh frequently, “air hunger”
Aware of “breathing heavily”
High altitude discomfort
Opens windows in closed rooms
Susceptible to colds and fevers
Afternoon “yawner”
Get “drowsy” often
Swollen ankles, worse at night
Muscle cramps; “charley horses”
Shortness of breath on exertion
Dull pain in chest or radiating into
left arm; worse on exertion
Bruise easily
Tendency to anemia
“Nose bleeds” frequent
Noises in head, or ringing in ears
Tension under the breastbone or
feeling of tightness; worse on
exertion
1
2
3
Group 5
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Dizziness
Dry skin
Burning feet
Blurred vision
Itching skin and feet
Excessive falling hair
Frequent skin rashes
Bitter, metallic taste in mouth in
mornings
73
74
75
76
77
78
79
80
425-830-4883
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81
O
O
O
82
83
O
O
O
O
O
O
84
85
86
87
88
89
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
90
O
O
O
91
92
O
O
O
O
O
O
93
94
95
96
97
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Bowel movements difficult or
painful
Worrier, feels insecure
Feeling queasy; headache over
eyes
Greasy foods upset
Stools light colored
Skin peels on foot soles
Pain between shoulder blades
Use laxatives
Stools alternate from soft to
watery
History of gallbladder attacks or
gallstones
Sneezing attacks
Dreaming, nightmare type bad
dreams
Bad breath (halitosis)
Milk products cause distress
Sensitive to hot water
Burning or itching anus
Crave sweets
1
2
3
Group 6
98
99
100
O
O
O
O
O
O
O
O
O
101
102
O
O
O
O
O
O
103
O
O
O
104
O
O
O
105
106
O
O
O
O
O
O
Loss of taste for meat
Lower bowel gas after eating
Burning stomach sensations,
eating relieves
Coated tongue
Pass large amounts of foulsmelling gas
Indigestion ½ - 1 hour after
eating; may be up to 3-4 hrs
Mucous colitis or “irritable
bowel”
Gas shortly after eating
Stomach “bloating” after eating
1
2
3
Group 7 - a
107
108
109
110
111
112
113
114
115
116
117
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
118
119
120
121
O
O
O
O
O
O
O
O
O
O
O
O
Insomnia
Nervousness
Can’t gain weight
Intolerant to heat
Highly emotional
Flush easily
Night sweats
Thin, moist skin
Inward trembling
Heart palpitates
Increased appetite without
weight gain
Pulse fast at rest
Eyelids and face twitch
Irritable and restless
Can’t work under pressure
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1
2
3
Group 7 - b
122
123
124
125
126
127
128
129
130
131
132
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
133
134
135
136
O
O
O
O
O
O
O
O
O
O
O
O
Increase in weight
Decrease in appetite
Fatigue easily
Ringing in ears
Sleepy during day
Sensitive to cold
Dry or scaly skin
Constipation
Mental sluggishness
Hair coarse, falls out
Headaches upon arising, wear
off during the day
Slow pulse, below 65
Frequency of urination
Impaired hearing
Reduced initiative
1
2
3
Group 7 - c
137
138
139
140
O
O
O
O
O
O
O
O
O
O
O
O
141
O
O
O
Failing memory
Low blood pressure
Increased sex drive
Headaches, “splitting or
rending” type
Decreased sugar tolerance
1
2
3
Group 7 - d
142
143
144
O
O
O
O
O
O
O
O
O
145
146
147
148
149
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Abnormal thirst
Bloating of abdomen
Weight gain around hips or
waist
Sex drive reduced or lacking
Tendency to ulcers, colitis
Increased sugar tolerance
Women: menstrual disorders
Young girls: lack of menstrual
function
1
2
3
Group 7 -e
150
151
152
153
154
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
155
156
O
O
O
O
O
O
Dizziness
Headaches
Hot flashes
Increase blood pressure
Hair growth on face or body
(female)
Sugar in urine (not diabetes)
Masculine tendencies (female)
1
2
3
Group 7 - f
O
O
O
O
O
O
Weakness, dizziness
Chronic fatigue
157
158
425-830-4883
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159
160
161
162
163
164
165
166
167
168
169
170
171
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
172
O
O
O
Low blood pressure
Nails weak, ridged
Tendency to hives
Arthritic tendencies
Perspiration increase
Bowel disorders
Poor circulation
Swollen ankles
Crave salt
Brown spots or bronzing of skin
Allergies; tendency to asthma
Weakness after colds, flu
Exhaustion – muscular and
nervous
Respiratory disorders
1
2
3
Group 8
173
174
175
176
177
178
179
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
180
181
182
183
O
O
O
O
O
O
O
O
O
O
O
O
184
185
186
187
188
189
190
191
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
192
O
O
O
193
194
195
O
O
O
O
O
O
O
O
O
196
197
198
199
O
O
O
O
O
O
O
O
O
O
O
O
Muscle weakness
Lack of stamina
Drowsiness after eating
Muscular soreness
Rapid heart beat
Hyper-irritable
Feeling of a band around your
head
Melancholia/sadness
Swelling of ankles
Diminished urination
Tendency to consume sweets or
crave carbohydrates
Muscle spasms
Blurred vision
Loss of muscular control
Numbness
Night sweats
Rapid digestion
Sensitivity to noise
Redness of palms of hands and
bottoms of feet
Visible veins on chest and
abdomen
Hemorrhoids
Apprehension
Nervousness causing loss of
appetite
Nervousness with indigestion
Gastritis
Forgetfulness
Thinning hair
1
2
3
Group 9 – FEMALE ONLY
O
O
O
O
O
O
O
O
O
Very easily fatigued
Premenstrual tension
Painful menses
200
201
202
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203
O
O
O
204
O
O
O
205
206
207
208
209
210
211
212
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Depressed feelings before
menstruation
Menstruation excessive and
prolonged
Painful breasts
Menstruate too frequently
Vaginal discharge
Hysterectomy / ovaries removed
Menopausal hot flashes
Menses scanty or missed
Acne, worse at menses
Depression
1
2
3
Group 10 – MALE ONLY
213
214
215
216
217
218
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
219
220
221
222
223
224
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
Prostate trouble
Urination difficult or dribbling
Night urination frequent
Depression
Pain on inside of legs or heels
Feeling of incomplete bowel
evacuation
Lack of energy
Migrating aches and pains
Tire too easily
Avoids activity
Leg nervousness at night
Diminished sex drive
List the 5 main complaints you have in order of their
importance:
425-830-4883
1.
______________________________________
2.
______________________________________
3.
______________________________________
4.
______________________________________
5.
______________________________________
erin@ezbalance.com
www.EZBalance.com
425-830-4883
erin@ezbalance.com