Practitioner: Rex Dance DCHM, Hbt, CCT, MNZAMH, NHC, MHBI

Complementary Therapeutics NZ Limited Copyright © 2015. All rights reserved.

Practitioner: Rex Dance DCHM, HbT, CCT, MNZAMH, NHC, MHBI.

Biographical data: Initial Consultation Questionare (including SKYPE)
Clients Name: ______D.O.B: ____/____/____
Address:______
______Phone:______
Alt Phone: ______Email: ______
Age:______Gender: ______
Relationship Status:______Children (Ages):______
Occupation:______Since when:______
Emergency Contact Person:______Phone:______
Relation to you:______
General Practitioner:______Phone:______
Religion/Cultural Considerations:______
Presenting Complaint(including nature, onset, progression, perceived cause, Influencing factors,
associated symptoms, Aggravated / alleviated by, Pain scale 1-10, Prevention of activities, )
PRESENT HEALTH CONCERNS
Time of first onset
Circumstances
Progression
Precipitating factors
Aggravating factors
Relieving factors
Associated symptoms
Previous diagnosis / treatmentsPlease include any significant lab results or imaging
Medical supervision
List all medications
Client goals
Body Systems Health Profile
G.I. / Digestive please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____Wt Change ____Dental Problems ____Nausea ____Indigestion ____Dysphagia (difficulty swallowing) ____Vomiting
____ Haematemis (vomiting up blood) ____ Acid reflux ____ Diarrhoea ____ Irritable bowel Syndrome
____ Anorexia nervosa ____ Diverticulitis ____ Mouth Ulcers ____ Bad breath ____ Duodenal Ulcer ____ Parasites
____ Bloating ____ Flatulence ____ Polyps ____ Bulimia ____ Gallstones ____ Receding Gums ____ Constipation
____ Haemorrhoids ____ Stomach ulcer ____ Crohn’s Disease ____ History of Hepatitis ____ Ulcerative colitis
____ Often forget to eat ____Strong appetite, eat regularly ____ Can skip meals easily ____ Anxious or faint if skip a meal ____ Get irritable if skip a meal ____ Prefer to eat 2-3 x a day ____ Bloated/heavy after eating
____ Heartburn/acidity after eating ____ Sleepy/heavy after eating ____Other:______
____ Abdominal pain ____ Loose stool ____Pale gray stool
____ Blood in stool ____ Food particles in stool ____ Pencil thin stool
____ Mucus in stool ____ Changes in bowel habits ____ Stool that floats ____ Painful defecation
____ Quick defecation after eating ____ Other: ______
How frequently do you have a bowel movement?
Are they generally on the harder or softer side?
Urinary System please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Bladder infections ____Painful urination ____ Cravings for salt
____ Kidney Stones ____ Lower back pain ____ Excessive fear/fearlessness
____ Water retention/oedema ____ Dark circles under eyes ____ Frequent urge to urinate
____ Dribbling/Incontinence ____Gout ____ Wake up at night to urinate
____ Excessive Urination ____Frequent thirst ____ Incomplete emptying of bladder ____ Difficult Starting
____ Loin Pain ____ Haematuria (blood in urine) ____ Poor Stream
Is your urine typically dark or light or clear in colour?
Reproductive FOR WOMEN ONLY
GYN/REPRO
REPRODUCTIVE WOMEN please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
Pregnancies (dates): ______
Miscarriages (dates): ______Abortions (dates): ______
Contraceptive use: List type and duration of use: ______
______
Sexually transmitted disease; List type if known: ______
Hysterectomy (date): ______Reason:______
____ Uterine Fibroids ____ Ovarian cysts ____ Endometriosis
____ Pelvic inflammatory disease ____ Cervical dysplasia ____ Infertility
____ Vaginal itching/discharge ____ Painful intercourse ____ Vaginal infection
____ Breast pain ____ Fibrocystic breasts ____ Lack of sex drive
Menstruating Women:
____ Absence of menstrual cycles ____ Irregular cycles ____Bleeding between cycles
____ Dramatic mood swings ____ Breast tenderness ____ Crave sugar before menses
____ Menses slow to start ____ Menses always lengthy ____Heavy bleeding
____ Painful menstrual cramps ____ Clots in menstrual blood ____ Anaemia
____ Menarche (age of first menstruation)
Please elaborate on any inconsistencies or concerns you have about your cycle:
_
______
Menopausal Women: please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Dry vaginal lining ____ Hormone replacement therapy ____ Sore muscles
____ Hot flashes ____ Mood swings ____ Night sweats
____ Osteoporosis ____ Estrogen replacement therapy Other: ______
______
REPRODUCTIVE MEN: please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
Sexually transmitted disease; List type if known: ______
____ Benign prostatic hypertrophy ____ Impotence ____ Painful ejaculation
____ Low sex drive ____ Low sperm count ____ Low sperm motility
____Premature ejaculation ____ Prostatitis ____ Difficulty with urination
____ Other:
Immune / Lymphatic System please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____Arthritis (rheumatism) ____ Autoimmune disorders ____Fibromyalgia
____Chronic fatigue ____ Neuralgia ____Frequent colds/infections
____ Low-grade fever ____ Low white blood cell count ____ Injuries heal slowly ____ Swollen lymph glands ____ Mononucleosis ____ Lyme disease ____ Lymphatic congestion ____ Feel “unclean” ____
Other: ______
Endocrine system please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Adrenal fatigue ____ Hypoglycaemia ____ Elevated Blood Sugar
____ Diabetes (type I or II?) ____ Metabolic Syndrome ____ Hypothyroid
____ Hyperthyroid ____ Overweight, difficulty loosing ____ Difficulty gaining weight
____ Pituitary ____ Pineal ____
Other: ______
Nervous System please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Sleep Disturbance ____ Dizziness/Vertigo ____ Fainting/Fits ____ Weakness ____ ADD/ADHD
____ Herpes or shingles outbreaks ____ Panic attacks ____ Anxiety ____ Depression ____Obsessive behaviour
____ Irritability ____Overwhelm ____ Numbness ____ Memory loss or changes ____ Mental fog ____ Stress
____ Headaches ____ Migraines ____ Insomnia ______Dreams
If you get headaches, can you describe the pain, location & triggers?
Which emotions do you experience most frequently? Please use o=often, s=sometimes, n=never
____ Anger ____ Joy ____Sadness ____Grief ____Worry
____ Irritability ____ Fear ____ Melancholy ____ Restlessness ____ Lethargy
____ Failing vision ____ Hearing loss ____ Tinnitus/ringing in ears
Heart & CVS please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____Chest Pain ____ SOBOE (shortness of breath on exertion) ____ Orthopnea (having to sit or stand to breathe properly)
____ Cold Extremities (hands and/or feet) ____ High blood pressure ____ Low Blood Pressure ____ High cholesterol
____Palpitations ____ Arteriosclerosis ____ Atherosclerosis ____ History of Heart attack ____ History of stoke
____ Congestive Heart Failure ____ Hands cold, clammy or dry ____ Hands warm, sweaty ____ Varicose Veins
____ Swelling in ankles/joints ____ Other: ______
Respiratory please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Ear aches ____ Ear infections ____ Sore gums
____ Sore throat ____ Laryngitis ____ Frequent nose bleeds
____ Frequent stuffy nose ____ Hayfever ____ Tonsils
____ Excessive Saliva ____ Difficulty swallowing ____ Other: ______
____Haemoptysis (coughing up blood)
____ Allergies ____ Difficulty breathing ____Wheezing
____ Asthma ____ Shortness of breath ____ Bronchitis
____ Cough ____ Fluid in lungs ____ Pleurisy
____ Postnasal drip ____Recurrent influenza ____ Cold
____ Sinusitis ____ Runny nose ____ Tuberculosis
____ Stuffy nose ____ Clear, thin mucus ____ Yellow/Green mucus
____ Dry, hard mucus ____ Easy to cough up mucus ____ Other: ______
Musculo-skeletal please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Joint Swelling ____ Arthritis (not rheumatoid) ____ Mobility restriction ____ Sprains
____ Backache upper/lower pain ____Broken bones ____ Tendonitis ____ Torn ligaments ____ Gout
____ Stiffness ____ Bursitis ____ Other: ______
SKIN please rate items as 1= sometimes 2= often 3= major concern or P = past condition. Leave blank if not applicable
____ Acne ____ Easily sunburned ____ Moles
____ Boils ____ Eczema and dermatitis ____ Rashes
____ Bleed or bruise easily ____ Psoriasis ____ Slow wound healing
____ Dry/itchy scalp or hair ____ red, burning or flushed skin ____Oily, damp scalp or hair
____ Fungal Infections ____Herpes (cold sores)
____ Other:
DIET
AM
MID AM
LUNCH
MID PM
DINNER
SUPPER
DRINKS
Oil Use
What foods do you crave? ______
What are your favourite and least favourite foods? ______
______
______
______
______
Do you have any known food allergies? No __ Yes __ List: ______
______
Do you consume any of the following: Please indicate: s= sometimes, o= often, n=never
_____ Soy products _____ Meat _____ Fish _____Eggs _____Dairy
_____ Beer _____ Wine _____ Coffee _____ Soda _____ Tea _____ Sugar _____ Candy _____ Baked goods _____ Processed foods _____ Fast food
_____ White Bread _____ Whole grain bread _____ Cold cereal _____ Whole grains or quinoa
_____ Raw veggies _____ Cooked veggies _____ Raw fruit _____ Dried or cooked fruit
_____ Fried foods _____Butter _____ Margarine or Earth Balance
_____ Canola, safflower, sunflower, soy or corn oils _____ Olive, coconut, sesame or palm oils
_____ Organic produce, grains ____ Pastured/Grass-fed eggs, poultry, meat and dairy
Do you often: Check all that apply
_____ Eat out more than once a week ____ Cook your meals at home
_____ Eat frozen/packaged foods ____ Cook your meals from scratch
_____ Feel rushed during your meals ____ Eat without distractions
_____ Eat while standing, reading, watching TV ____ Eat regularly timed meals
_____ Over eat ____ Eat until satiated or just under
Client Consent
I, ______(Full NAME), give consent for my health information to be documented and appropriate physical examinations and assessments to be performed. I understand that following the consultation a treatment plan will be created for me after agreement between myself and the practitioner. I will give the practitioner all personal information needed to perform a safe and successful treatment.
I am aware that both practitioner and I have the right to stop the consultation procedure and / or treatment at any time.
Client signature:______DATE:______
Practitioner Signature:______

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