Client Health Consultation Survey

Client Health Consultation Questionnaire
Full Name*
First NameLast Name
Birth Date*
MonthDayYear
E-mail*
Skype E-mail
Phone Number
Area CodePhone Number
Height*
Weight*
Waist Circumference*
MaleFemaleOther
What are the main reasons you are seeking health care advice?*
Weight lossDisease PreventionDigestive SupportStress ManagementEnergyDetoxPre-conception & Pregnancy CareCardiovascular ProtectionDietary AdviceImmune SystemPain ManagementOther
What are your major health concerns?*
Have you been diagnosed with a condition pertaining you your concern(s)?
YesNo
What are your health goals*
How committed are you to healing yourself and changing your lifestyle?*

1 2 3 4 5 6 7 8 9 10
1 is Not at All, 10 is 100% All in!
How do you rate your current level of health?*

1 2 3 4 5 6 7 8 9 10
1 is Not Great, 10 is 100% Excellent
How do you rate your current level of energy or vitality?*

1 2 3 4 5 6 7 8 9 10
1 is Not Much, 10 is 100% Excellent
How do you rate your current stress levels?*

1 2 3 4 5 6 7 8 9 10
1 is Not Much, 10 is 100% Over Board
Do you have trouble getting to sleep?*

1 2 3 4 5 6 7 8 9 10
1 is Very Little, 10 is 100% Just Right
How many hours sleep do you get a night?*
Do you wake often, or get woken easily?*
Do you have to go to the bathroom during the night?*
How often during the night*
Do you snore or have breathing problems during sleep?*
Do you have known allergies?*
Please list any known allergies
What herbs, vitamins, supplements or medications are you taking?*
Do you engage in physical activity on a regular basis?
YesNo
In general, what has been your mental state over the last 48 hours?
Calm and contentAgitated and annoyed
Do you smoke?
YesNo
Do you drink caffeine?
YesNo
Do you drink alcohol?
YesNo
Does a member of your household drink alcohol, smoke or drink caffeine?
YesNo
Do you feel you get enough sleep?
YesNo
What foods have you eaten in the last 24 hours? Please include as many as possible and how they were prepared.
Which natural health products and therapies do you use or have you used in the past?
YogaAcupunctureAcupressureReikiHerbal medicineMassageMeditationAyurvedaAromatherapyTraditional Chinese MedicineOther

Family History
Please provide any relevant, and major issues pertaining to your family members' health.
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:

Prior to obtaining the services of Health And Wellness: Stacy-Ann Champagnie, I certify that I clearly understand the following:

I choose to consult with Stacy-Ann Champagnie as a natural herbal health counselor who conveys self-help information that people can use to enhance wellbeing. I affirm my right to self-health, and I take full responsibility for my healing process with her guidance and support. I state that I come to Stacy-Ann with the purest of heart and purpose of seeking information. I state that I do not come with any forethought or will have any afterthought to entrap Stacy-Ann into an illegal statement or action. I understand that Stacy-Ann's sole intention is to offer educational information that will help to bring homeostasis into my body/condition. If I choose to use this information for myself or loved ones, then I affirm that the responsibility is mine. I understand that Stacy-Ann does not provide legal medical services, but instead suggestions that I can choose to use for healing. I will not consider her advice or anything that she says to replace the treatment of a licensed primary healthcare provider or medical doctor. Stacy-Ann is not a licensed health care provider or a medical doctor. She does not diagnose, prescribes, or treat symptoms, defects, injuries, or diseases.
Stacy-Ann Champagnie does business as Get Healthy

Please read and sign to acknowledge that you understand and agree to the above statements. You will not be helped without it.
Thank you!
Signature
Clear
e-Signature*
First NameLast Name
Date*
MonthDayYear
Have you already scheduled a follow up meeting with Stacy-Ann?
YesNo

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