Health Questionnaire

  • BASIC INFO

  • MM slash DD slash YYYY


  • HISTORY

  • (or indicate if they are no longer living)
  • (or indicate if they are no longer living)
  • (or indicate if they are no longer living)
  • Briefly describe your symptoms, chosen treatment(s) and dates
  • FOOD & DIET

  • If different on weekdays and weekends, please include both.
  • If different on weekdays and weekends, please include both.
  • If different on weekdays and weekends, please include both.
  • How often & how much do you have of each?

  • Supplements & Medication

  • Digestion

  • Energy, Mood & Sleep

  • (10 being highest, 1 being lowest)
  • (10 being happiest, 1 being most depressed/anxious)
  • (10 being highest/most stressed, 1 being least stressed)
  • Reproductive Health

  • pain with intercourse, dryness, libido issues, erectile dysfunction, etc
  • Women Only

  • Last Questions