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Pure Wellness Health Questionnaire
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* Indicates required question
Name
*
Your answer
Email
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Place of Birth
*
Your answer
Age:
Gender:
Female
Male
Clear selection
Height:
Your answer
Weight:
Your answer
Would you like your weight to be different:
Yes
No
Maybe
Clear selection
If so, what is your goal weight?
Your answer
Occupations:
Your answer
How many hours do you work per week?
Your answer
Do you work nights?
Yes
No
Clear selection
Relationship Status:
Single
Married
Separated
Divorced
CHILD
Clear selection
Do you have children?
Yes
No
Clear selection
Please list your blood type if you know it>
Your answer
Please list any known Blood Factors/Genetic Diagnosis Ex: RH-, mthfr, etc
Your answer
Hobbies/Activities:
Your answer
Please list your top 5 health concerns:
Your answer
Do you sleep well at night?
Yes
No
Varries
Clear selection
Do you wake up during the night?
Yes
No
Sometimes
Only if I have to use the bathroom
Clear selection
What time do you go to bed
Your answer
Do you fall to sleep easily?
Yes
No
Sometimes
Clear selection
What time do you wake up?
Your answer
Do you drink caffeinated drinks?
Yes - several every day
No
Rarely
Yes - 1 every day
Clear selection
Do you drink soda?
Yes - several every day
No
Rarely
Yes - 1 every day
Clear selection
Have you ever smoked?
Current Smoker
Never
Rarely
A long time ago
Other:
Clear selection
Have you had exposure to second hand smoke?
Yes
No
Sometimes
A long time ago
Other:
Clear selection
Do you drink alcohol?
Yes
No
Sometimes
A long time ago
Other:
Clear selection
What role does exercise play in your life?
I don't work out
I walk
2-3 x per week
I get my exercise from my hobbies
Its a part of my daily routine
Other:
Clear selection
Do you like to work out?
I love it
I do it because i know I should
I don't like to exercise
Other:
Clear selection
Do you follow a lifestyle eating plan (atkins, paleo, keto, weight watchers)? If so, please list:
Your answer
Have you been exposed to toxic chemicals or mold (at work or home)?
Yes
No
I think so
Clear selection
Please list ALL prescription medication you are currently taking:
Your answer
Do you use "recreational drugs"?
Yes
No
Occasionally
Clear selection
Have you taken antibiotics or steroids in the last 2 years?
Yes, antibiotics
No
Yes, steroids
Yes, antibiotics and steroids
Other:
Clear selection
Please list ALL supplements that you are taking or have taken in the last 12 months:
Your answer
Do you have allergies to medication or herbs? If so, please list:
Your answer
Are you currently under a practitioners care for a specific health issues? If so, please list the practitioners information and what they are helping you with:
Your answer
Are you currently under a practitioners care for a specific health issues? If so, please list the practitioners information and what they are helping you with:
Your answer
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and approximate date:
Your answer
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and approximate date:
Your answer
What were your eating habits like as a child: Please list food types:
Your answer
What percentage of your food is home cooked:
Your answer
How often do you eat out?
Your answer
Please list your favorite things to eat:
Your answer
What do you think are the most healthy foods that you eat each week? Please list all 3
Your answer
What are the worst foods that you eat each week?
Your answer
Do you crave salt or sugar?
Just Sugar
Just Salt
Both
Neither
Clear selection
Do you feel tired, bloated or gassy after meals?
Just Tired
Bloated
Gassy
All 3
None
Other:
Clear selection
Do you feel excessively hungry?
Yes
No
Sometimes
Clear selection
Do you have a poor appetite?
Yes
No
Sometimes
Clear selection
Do you experience constipation or diarrhea often?
Both
No
Yes - Constipation
Yes - Diarrhea
Clear selection
Do you have trouble focusing or have issues with "brain fog"?
Yes
No
Yes - Brain fog
Yes - Focus is a problem
Both
Clear selection
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