CLIENT INFORMATION Please submit this form no later than 24 hours prior to the scheduled appointment. If you have any questions or encounter any difficulties, please contact eileen@havelifelongwellbeing.comNOTE: You will be asked to complete a food journal on the next page. To do so, you will need to record everything you eat and drink for 4 consecutive typical days. It is not necessary to measure amounts, but rather just to list the foods and beverages you consume. Please record this information PRIOR to filling in the form so that you can answer accurately and honestly. You will NOT be able to save the form and continue later, so be sure to have this information ready before starting!Click here to download a food journal template to make tracking easier. Client Name (First & Last Name) Phone Email Address Height Weight Date of Birth FOOD JOURNAL Please record everything you eat and drink for 4 consecutive typical days. It is not necessary to measure amounts, but rather just to list the foods and beverages you consume. Click here to download a printable food journal to help with tracking. NOTE: You must complete this section at the same time as the rest of your form, you cannot return to fill it in later! Day 1 Breakfast AM Snacks / Meals Lunch PM Snacks / Meals Dinner Evening Snacks / Meals Water Consumed (in ounces) Day 2 Breakfast AM Snacks / Meals Lunch PM Snacks / Meals Dinner Evening Snacks / Meals Water Consumed (in ounces) Day 3 Breakfast AM Snacks / Meals Lunch PM Snacks / Meals Dinner Evening Snacks / Meals Water Consumed (in ounces) Day 4 Breakfast AM Snacks / Meals Lunch PM Snacks / Meals Dinner Evening Snacks / Meals Water Consumed (in ounces) MEDICAL INFORMATION I have been diagnosed as having: List any tests you have had or imaging results received: List all prescription medications you are CURRENTLY taking: List medications you have taken in the PAST: List all non-prescription medications you are using and how often you use them (Tylenol, Tums, etc.): List all vitamins and supplements you are taking, along with dosages and frequency of use: List all major and minor injuries, including automobile accidents: List any surgeries you have had: PAIN & SYMPTOMS List all of your recurring symptoms: Do you experience pain regularly? Where? Do you experience any bloating, recurrent gas, diarrhea or constipation? Describe. List the sources of your stress: What have you done that has made you feel better? (if applicable) Describe your exercise program (if applicable): Please select all of the following that apply to you: I sometimes leak urine when I cough/sneeze/laugh I have a strong urge to go to the bathroom often during the day I wake up more than 1 time per night to use the bathroom I have a sensation of incomplete emptying of bladder or bowels I have pelvic/groin pain I have pain or dysfunction with intercourse I feel heaviness or pressure in the pelvic area I have painful periods List or describe anything else that is of concern to you: YOUR GOALS What’s the most important goal in your personal life right now around your health and physical ability? What would you like to accomplish in the next year in your health and physical ability? What’s the biggest challenge that’s preventing you from this goal? If that problem were solved right now in your life; what would it mean to you (and your family)? STRESS SYMPTOM SURVEY Check off all of the symptoms below that apply to you. Physical Stress Symptoms Backache Soreness, tightness in shoulders or neck Persistent cough Chronic infections Hives Skin rashes Itchy skin Fatigue Insomnia Headache Anxiety Clenching teeth Muscle spasms Nail biting Heart palpitations/racing heart Stomach ache Breathing difficulties Infertility Nausea Sweaty Palms Ringing in the ears Restlessness Cold Hands Behavioral Stress Symptoms Addictive behavior Aggression Hyper-critical of self and others Nervous habits such as pacing, foot tapping Compulsive eating Biting fingernails Inability to get things done Forgetfulness Inability to make decisions Constant worry Loss of sense of humor Crying for no reason Emotional Stress Symptoms Feeling powerless Overwhelming sense of pressure Anxiety Edginess Easily upset Excessive anger Unhappy for no reason Feeling that you have no purpose Loneliness Despair Inability to let go Constant fear Time's up