Client First Time Evaluation Form

Please Note:

• Prior to your very first consultation, could you please fill-in the information requested contained within this form and send it to me by clicking on the Submit Button at the bottom of the form.
• Questions with a red * to the right must be answered.
• If you do not get the 'Thank You' message after clicking on the Submit Button to send the form to Angela, there will be items that you have missed when entering data into the form. A message will appear near the top of the form. Please review the form, make corrections/additions and then click on the Submit Button.
• All information is kept strictly confidential. The detail is used to allow me time to review your health basics and focus on priorities during your consultation.
• Drink adequate water before your consultation (good hydration required for QRA checks).
• Try to avoid coffee/alcohol immediately before your consultation (effects conventional as well as alternative diagnostic techniques).
• If you have any recent/relevant blood tests or medical reports, please bring these with you (request a copy from your doctor’s clinic or specialist).

 

Surname & First Names *

Sex Female or Male Female
Male

Age in Years

Date of Birth

Address *

City/Town *

A Contact Land Line Phone Number

Mobile

email address

Your Doctors Name

Referred by

Complaint Details (1000 chars left)

Health Details (1000 chars left)

Medication Details (1000 chars left)

Supplement Details (1000 chars left)

Surgery Details (1000 chars left)

Dental Work Information

Current Smoker? Yes
No

How long have you smoked?

How Many Cigarettes per day?

Ex-smoker Yes No

Between what ages did you smoke?

How many cigarettes per day did you smoke?

How often do you drink alcohol? Every Day
Most Days
Once or Twice a Week
Three or four times a week
Special Occasions
Never Drink Alcohol

When you do drink, what (wine, beer etc) & how much do you consume?

What Recreational Drugs do you use?

Please provide information on how long you have used the drug and how much you regularly consume?

Please rate your current stress level (on a scale of 1 to 10, 10 being the highest stress): One Two Three Four Five Six Seven Eight Nine Ten

What is the main reason(s) for your stress?

Mother Illnesses (500 chars left)

Father Illnesses (500 chars left)

Siblings Illnesses (500 chars left)

Your children Illnesses (500 chars left)

Any notable illnesses in past/present extended family members? (500 chars left)

How is your sleep? Select options that describe your sleep patterns. Restful
Restless
Hard to get to sleep
Wake up often
Get up during the night
Bad dreams

Other Sleep Symptoms? (300 chars left)

What time do you usually go to sleep?

What time do you usually awake?

Is your bedroom Dark or Light (select from list) Dark
Quite light

Which of the following best describes your digestive health/symptoms: Adequate
Poor
Acid reflux
Burp often
Burning/pain in stomach
Bloating
Other symptoms

How often do you pass stools (poo)?

If you do skip days, how many days typically is it before having a bowel motion?

Stool Amount: Normal
Too little
Too large

Stool Consistency: Normal
Too hard
Very soft
Diarrhea

Stool Colour: Brown
Black
Yellowish
Other

Other Stool Issues: None
Lots of mucus
Lots of gas
Foul smell

Describe any pain:

Any other Stool related symptoms:

How often do you urinate? Every 2 to 3 hours
Too frequently
Infrequently

Urination problems: None
Sense of urgency
Too small amount
Too large amount
Burning
Dribbling
Unusual smell

Do you need to get up out of bed & urinate several times over night? No Sometimes Yes, often Always *

Describe any other urination Problems?

Are you pregnant? Not Applicable
Yes
No

Are you breastfeeding? Not Applicable
Yes
No

Are your monthly periods regular (around 28 days cycles)? Not Applicable
Yes
No

Number of days of menstrual flow?

Symptoms experience associated with your period: Not Applicable
None
Cramping
Bloating
Feeling weak
Mood swings
Cravings
Heavy bleeding
Back pain
Headaches
Bright red blood
Dark clotted blood

Any other menstrual symptoms or changes? (500 chars left)

Do you have children? Not Applicable
Yes
No

How old are your children?

Have your periods stopped? Not Applicable
Yes
No

Have your periods changed or become irregular (please detail)? (500 chars left)

Have you had a Hysterectomy? Not Applicable
Yes
No

If you have had a Hysterectomy, when did you have it and why?

Please detail any other symptoms of menopause you are experiencing: (500 chars left)

Do you exercise? Yes I exercise
Incidental exercise
No exercise

If so, what kinds of exercise do you participate in?

How often do you exercise?

When you exercise, how much time do you spend exercising?

Breakfast:

Morning snack:

Lunch:

Afternoon snack:

Evening snack:

Red meat meals:

Chicken meals:

Fish meals:

Egg meals:

Vegetarian:

Coffee:

Tea:

Green tea:

Herb tea (please name type of teas):

Water:

Milk:

Choice of milk type (if any):

What type of Spread do you use? Butter Margarine Other I do not use spreed

How many vegetable serves per day do you consume (1 serve = ½ cup when raw)

Fruit - Choice and number of fruit per day

Tick boxes that best describes your diet preferences/habits (you can tick more than one if required): Mostly eat out (fast food)
Mostly eat out (but try to eat healthier items)
Eat whatever is available
Occasional binges
Skip meals often
Eat a lot of convenience food (boxed/packet foods, etc)
Eat mostly homemade meals
Vegetarian
Vegan
Mostly organic
A lot of raw food
In transition of eating better

Do you work? I work full-time I work part-time I do not work I’m currently not working

Employment/Self-employment History: What kind of work do you (or did you) do? (500 chars left)

If employed, how many hours do you work a week?

Please select your preferred day Any day that is available
Monday
Wednesday
Thursday
Friday
*

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Thank You for completing the information and sending me your information.  I will be in touch soon to arrange an appointment.

 

Angela Frieswyk, BSc, Dipl Herb Med, NZAMH