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New Client Questionnaire

New Client Questionnaire

Please take your time to complete this questionnaire carefully and truthfully, if you feel there are sections that are irrelevant to your condition, feel free to leave it blank. Please keep in mind the more information you provide to us will help us to structure the best possible and effective treatment protocol for you. Any information provided will be kept completely confidential and confined to Clarity Natural Health.

  • Client Information & History
  • Dietary Habit Analysis
  • Energy / Stress / Sleep
  • Digestive / Kidney / Skin / Circulation
  • Musculoskeletal / Reproductive / Respiratory / Detoxification

Client Information

Gender

Health Concern & History

Dietary Habit Analysis

Do you eat more packaged (frozen/canned) fruits and vegetables or more vegetables than fresh?

Do you eat vegetables with less than two meals daily?

How often do you eat organic or non-organic produce?

How often do you use the microwave?

Do you eat white breads/grains more often than wholegrain breads/grains?

How frequently do you drink pasteurised/homogenised milk?

Do you eat red meat more than 3 times a week?

Do you eat canned fish more frequently than fresh fish?

Do you use commercial salad dressings?

Do you use margarine or products that contain Canola oil or hydrogenated oils? (Trans fat)

Do you use white table sugar?

Do you use artificial sweeteners?

How often would you eat fast food from restaurants like McDonalds, KFC, etc.

Do you drink tap water or filtered water?

Do you frequently and purposely skip meals?

Do you avoid fats when eating? (You tend to opt. For the low-fat or fat free option)

Do you frequently snack on quick carbohydrates? (Candy, chocolates, cookies, crackers)

Energy

What is your best time of day?

Energetically, do you make it through the day okay?

How often would you say you experience mental fatigue or brain-fog?

Stress & Mental Health

How often do you worry over job, income or money problems?

Do you have any relationships that are causing you stress?

How often would you say you experience anxiety?

How often would you say you experience feelings of isolation, loneliness or depression?

Do you get noticeably upset when things go wrong?

Do you feel that you worry a lot?

Do you tend to lash out at others?

Sleep & Circadian Health

How often do you wake up feeling un-rested and in need of more sleep?

How often would you say you go to bed after 10:30pm?

Are your bowel movements consistent and predictable on a daily basis?

Do you travel across time zones more than once a month?

Do you do shift work that requires you to stay up late at night?

(If relevant) Do you wake up at night between 1:00am to 4:00am and have a hard time falling back to sleep?

How often do you use a device/tv an hour before bed?

Digestive Health

How often do you use your bowels?

Do you experience any lower abdominal bloating?

Do you frequency have loose stools or diarrhoea?

Do you experience constipation or stools that are hard to pass?

Do you experience any excessive burping/belching after meals?

Do you experience any excessive gas?

Do you experience any frequent abdominal pain, cramps or general abdominal discomfort?

Do you have a poor appetite and/or feel worse after eating?

Do you get a headache after eating?

Kidney Health

Do you suffer from any frequent excessive thirst?

How much water do you drink daily?

Do you suffer from fluid retention?

Is there ever any noticeable colour, sediment, cloudiness, foaminess or odour in your urine?

History of thrush or UTIs?

Do you find your perspire a lot?

Skin Health

Do you suffer from any skin conditions? (Psoriasis, Eczema, etc)

Do you find your skin is slower to heal? (Cuts, bruises, etc).

Does your skin ever feel too dry?

Does your skin ever feel too oily?

Thermal & Circulation Health

Are you affected by the weather? (Hay-fever, emotional upset, etc)

Do you feel the heat or cold more?

History of heart problems or other cardiovascular related conditions? (High/Low blood pressure, etc)

Have you ever been diagnosed with low iron or anaemia?

Do you ever experience any faintness or dizziness?

Experience any frequent chest pains?

Musculoskeletal Health

Experience any frequent/re-ocurring muscle pain?

Experience any frequent/re-courring joint pain?

Experience any frequent/re-ocurring cramping?

Reproductive Health - Female (Disregard if male)

How regular is your period?

How long would you say you menstruate for?

How heavy or light is the flow?

How often do you experience blood clotting?

Reproductive Health - Male (Disregard if female)

Have you ever had your prostate checked?

Do you have any problems with urinary flow?

Do you experience any painful urination?

Any issues with sustaining or maintaining an errection?

Respiratory Health

History of frequent sinus or hay fever?

History of lung or chest infections/complaints?

History of shortness of breath?

Do you suffer from any frequent mouth, throat or ear problems?

Detoxification

Do you suffer from irritability or have difficulty relaxing?

How often would you say you feel fatigued and/or sluggish?

Do you suffer from frequent headaches?

Do you experience mental sluggishness, poor memory or poor concentration?

Do you find it easy to lose weight?

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