Please copy and paste this questionnaire onto a word doc. Then fill it in and attach as an email to me at dianelsolomon2@yahoo.com. OR print it out, fill it in by hand and bring to your appointment.
QUESTIONNAIRE
Please use capital letters in your answers if you are attaching this doc to an email, so I can easily see your answers, thanks.
NAME _________________________________________
ADDRESS______________________________________ _______________________________
EMAIL ADDRESS:
PHONE: DAY____________ EVENING ____________ : ____________________
CELL
AGE:_____ SEX _________ MARITAL STATUS ______
CHILDREN _____________________________________
BIRTHDATE:__________
WEIGHT______ HEIGHT_____ OCCUPATION______
HEALTH HISTORY: PLEASE CHECK
MUMPS ______ COLD SORES_____ PNEUMONIA _____
MONONUCLEOSIS______ CHICKENPOX _____ HERPES ___
POLIO ___ SHINGLES _____ MEASLES_____ MALARIA ___
HEPATITIS ___ TUBERCULOSIS ___ MENINGITIS ______
WHOOPING COUGH ________
CANCER: Please explain:
__________________________________________________
__________________________________________________
OTHER: ___________________________________________
HEALTH PROFILE: Please list all the health problems you would like to clear up,
and indicate how long you have had those problems. i.e.: Headaches 5 years.
1.________________________________________________
2.________________________________________________
3.________________________________________________
4.________________________________________________
5.________________________________________________
6._________________________________________________
What medications do you take for these conditions, if any? State daily dosage:
__________________________________________________
What operations have you had?
__________________________________________________
__________________________________________________
What vitamins, mineral, herbs do you regularly take?
_______________________________________________
_______________________________________________
How much alcohol do you drink?________________
Do you smoke?____________
What is your normal blood pressure? __________
What is your cholesterol reading? ____________
if you know it, HDL?____________ LDL_________?
HEREDITARY PROFILE What illness is/was your father prone?
_____________________________________________________
_____________________________________________________
What illnesses is/was your mother prone to?
_____________________________________________________
_____________________________________________________
How many brothers and sisters do you have? State age and sex:
_____________________________________________________
_____________________________________________________
Are there any particular illness that they suffer from?
_____________________________________________________
_____________________________________________________
What health problems do your grandparents have/had?__________
____________________________________________________
_____________________________________________________
____________________________________________________
Is there any diabetes, tuberculosis, alcoholism, birth defects, anxiety, or
depression in the family tree?
____________________________________________________
____________________________________________________
_____________________________________________________
State age and sex of your children__________________________
How many silver amalgam fillings?_________
Root canal work?___________________________
What symptom or health problem bothers you the most? (I.e. headaches, fatigue, arthritis, muscle aches, depression, etc.)
_______________________________________________________
_______________________________________________________
Please describe how the symptom or pain FEELS in detail: describe the SENSATION: _______________________________________________________
_______________________________________________________
What if anything, makes it better? (i.e; time of day/night, season, cold/warm applications, hot/cold drinks, eating, motion, rest, sleep, open air, comfort, pressure, exercise, etc:
________________________________________________________
________________________________________________________
Similarly, what makes it worse? ______________________________
______________________________________________________
What is your second main symptom?__________________________
______________________________________________________
Please describe how the symptom/pain FEELS in detail: again, describe the SENSATION:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What makes it better?__________________________________________________
____________________________________________________________________
What makes it worse?__________________________________________________
____________________________________________________________________
What other symptoms bother you? Please describe:_________________________
____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
How do you sleep? Wake up easily? Wake often in the night, to urinate, or hungry?
Heavy dreaming? Please describe:
_____________________________________________________________________
_____________________________________________________________________
In what position do you sleep?___________________________________________
What time of day or night do you feel the worst? ________________
The best ? _________________
FOR WOMEN ONLY: Describe your periods; pain? regularity, how long does
your flow last, how copious the flow, mood before, during, after?
____________________________________________________________________
____________________________________________________________________
What foods/drinks do you long for?
____________________________________________________________________
Any that you loathe or are averse to?_____________________________________
Would you rather be alone, or with people?____________ Do people make you
uncomfortable or fearful? ___________
When you are ill, does comforting make you irritable? __________________
Please rate all on a scale of 1-10:
How anxious are you?____ How fearful?_____ Nervous?_____ Sad? _____
Irritable? _____ Startle easily? _____ Optimistic?_______ Negative?_____
Depressed? ______ Impatient? _________Are you offended easily?______
How high Is your energy level? _____ How high is your sex drive? _____
How restless are you?________ How thirsty? ________
If so, for cold drinks? ___________ or warm? __________
How good is your mental concentration? _________
Is your mood changeable? ___________
If you have pain, describe the sensation in detail: burning, like needles, with
numbness, hot, pulsating, does it come and go quickly, how do you act during the
pain? Mention anything that seems unusual:
____________________________________________________________________
____________________________________________________________________
Do you feel the cold? ________ Do you have cold hands and feet?_________
Or do you usually feel warm? _________ Do you love open windows? ________
Do you feel better in the open air? _______
Do you love to be all covered up? _______
Do you love thrills? _______ Disneyland rides? ________
Do you like to live on the edge? _______________________________
List any other symptoms or things that seem strange to you relating to the following parts of the body:
Ears.__________________________________________________________________
Nose:_________________________________________________________________
Mouth/Tongue:_________________________________________________________
Throat:_______________________________________________________________
Eyes:_________________________________________________________________
Head:_________________________________________________________________
Skin___________________________________________________________________
Extremities: (arms, legs, hands, feet): _____________________________________
______________________________________________________________________
Perspiration:___________________________________________________________
Urination:_____________________________________________________________
Stools,Anus:__________________________________________________________
Hair/Nails:____________________________________________________________
Heart:_______________________________________________________________
Abdomen:_____________________________________________________________
Sleep:_______________________________________________________________
OTHER: ______________________________________________________________
_____________________________________________________________________
Do you itch anywhere? When, and what makes it better or worse?
_____________________________________________________________________
Please describe your character, personality and emotional state:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What is your main psychological or emotional issue in life? (i.e. fear, anxiety, financial security, anger, expressing emotions, self-worth, fear of death, etc.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Describe any other strange peculiarities of yours, (i.e. music makes you cry, you have very odd dreams, you’re very hungry for food, then lose your appetite when you start to eat, you long for death, you feel better from sunshine or in a storm, you get your words mixed up, you have an irrational fear of a dog, a burglar, you must wait to urinate, you are intensely sympathetic to other people’s pain, you’re a “people pleaser”, etc. Jot it down no matter how odd it might seem: _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Do you have any irrational fears? ________________________________________
____________________________________________________________________
Are you a leader or a follower? _____________ Are you a loner?_______________
Do you like or dislike consolation and comforting when you are unwell or irritable?
___________________________________________________________________
Do you like to be touched?______________________________
Do you feel indifferent to people you know you love?_________________________
Do you have any addictive or compulsive behavior? If so, please describe :
____________________________________________________________________
_____________________________________________________________________
Do you go more easily to anger or tears?
_______________________________________________
Are you a perfectionist?________________________________________________
Do you save things?____________________________________________________
Do you like a tidy environment or are you unbothered by a mess?______________
How do you feel about personal hygiene?__________________________________
Do you love to take a shower or bath or is it more trouble than it is worth?
____________________________________________________________________
Do you like scary movies?______________________________________________
Describe your sense of self-worth:________________________________________
_____________________________________________________________________
Are you uncomfortable around or afraid of people?___________________________
Do you have recurring dreams? Please describe:_____________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What was your relationship like with your mother amd father?_________________
____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Diane Solomon
Dianelsolomon2@gmail.com
www.solomonhealing.com