Blueprint Wellness Health Coaching Questionnaire
Please complete all of the questions to the best of your ability!
Email *
First Name *
Last Name *
Today's Date *
Birth Date *
Age *
Height (feet, inches) *
Weight (lbs) *
Gender *
City *
State *
Zip *
Email Address *
Phone Number *
Time Zone *
Skype Name (If a skype user)
Occupation *
Referred By *
Describe problem/symptoms *
What treatments have you tried? *
Has anything been successful? *
With whom do you live? *
(Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister
Do you have any pets or farm animals? If yes, where do they live? *
Have you lived or traveled outside of the United States? If so, when and where? *
Have you or your family recently experienced any major life changes? If yes, please explain
Have you experienced any major losses in life? If so, please explain:
How much time have you lost from work or school in the past year?
Previous Jobs/Occupations
Did you feel safe growing up? *
Have you been involved in abusive relationships in your life? *
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *
Do you feel safe, respected and valued in your current relationship? *
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? * *
Would you feel safer discussing any of these issues privately OR Would you prefer not to speak about these issues?
Clear selection
Please list any allergies or intolerances (food or environmental) *
List past Medical and Surgical History *
List previous hospitalizations *
How often have you taken antibiotics (As a child or adult) *
How often have you taken oral steroids? *
(ex. cortisone, Prednisone, etc.)
What medications are you taking now? *
(including birth control/hormones)
List all vitamins, minerals, and other nutritional supplements that you are taking now *
Were you a full term baby? A preemie? Breast-fed or Bottle-fed? *
As a child did you eat a lot of processed sugar and/or candy? *
What is your typical daily diet like? *
(List typical meals and snacks)
How much of the following do you consume each week? *
(Tea, coffee, soda, dairy, bread, candy, chocolate, other dessert)
Are you on a special diet? If so, is there anything special we should know about it? *
Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s) *
Do you feel much worse when you eat certain foods? *
Example: Fat, protein, carbs, etc.
Do you feel much better when you eat certain foods? *
Example: Fat, protein, carbs, etc.
Have you ever had a food that you craved or really "binged" on over a period of time? *
Do you have an aversion to certain foods? If yes, what foods? *
How many bowel movements (BM) do you have per day? *
Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? *
Do you have intestinal gas? If so, when. *
How many times per week do you drink alcohol? *
Have you ever used recreational drugs? *
Have you ever used tobacco? (If so, for how long?) *
Are you exposed to secondhand smoke regularly? *
Do you have mercury amalgam fillings in your teeth? If so, how many? *
Do you have any artificial joints or implants? If so, which ones *
Do you feel worse at certain times of the year? *
Have you, to your knowledge, been exposed to toxic metals in your job or at home? * *
Do certain odors affect you? If so, which ones? *
How would you rate your current level of stress? *
Very Low
Very High
Women: If you have a cycle, how long is it and is it regular?
Women: Do you have any problematic symptoms related to your cycle?
flow, clots, mood changes, etc.
List your hobbies and leisure activities: *
Do you exercise regularly? If so, how many times a week? *
What type of exercise is it?
Do you struggle with insomnia or interrupted sleep? *
Do your parents or siblings have (or had) any health issues? If so, please explain:
Please add any other information you feel is important:
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