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SPE Client Information

SPE INTAKE

Name
First Last
Date
Date Format: MM slash DD slash YYYY
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Referred By:
How often do you check e-mail?
How do you prefer to be contacted?
What are your main health concerns:
Do you have any other concerns?
Health History
Age
Height:
Date of Birth:
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different? If so, what?
Any serious illnesses/hospitalizations/injuries?
Do you sleep well?
How many hours?
Do you wake up at night? If so, why?
Date of Last check-up:
Are you presently under a doctor’s care? Explain:
Any pain, stiffness or swelling?
Allergies or sensitivities?
Do you take any supplements or medications? Prescription? Non-Prescription?
Are you aware of any side effects of your medication?
Any healers, helpers or therapies with which you are involved?
What role does sports and exercise play in your life?
Please describe any allergies (Food, Medication, Perfumes, Other)
History of:
- Epilepsy
- Headaches
- Insomnia
- Stress
- Skin Rashes
- Dizziness
- Lack of Energy
- Asthma
- Pregnancy
- Breast Feeding
Most Favorite Aroma/Scent/Smells:
Least Favorite Aroma/Scent/Smells:
Reason for, and expected benefit from this consultation:
Please describe any family history of cancer or immune deficiency?
Environmental Concerns
Do you experience any of the following symptoms breathing in-door air?
- Headaches at home
- Headaches at work
- Eye/nose/throat irritation at home
- Eye/nose/throat irritation at work
- Dry Cough at home
- Dry Cough at work
- Dry or itchy skin at home
- Dry or itchy skin at work
- Dizziness & Nausea at home
- Dizziness & Nausea at work
- Difficulty concentrating at home
- Difficulty concentrating at work
- Fatigue &/or Sensitivity to odors home
- Fatigue &/or Sensitivity to odors work
Do you feel relief soon after leaving the building?
- Home
- Work
Have you informed your doctor about this occurrence?
- Home
- Work
How often do you air out your home:
- Every week
- Every 2 weeks
- Once per Month
- Never
How long have you been living in your present home?
How long have you been working in the same building?
Check products used for personal care:
- Toothpaste
- Body Powder
- Deodorant
- Foot Powder
- Mouthwash
- Bath Salts
- Other
Check products used for Home use:
- Room Deodorizers
- Kitchen Counter Cleaners’Wood Polish
- Carpet Cleaner
- Dishwashing Detergents
- Insecticides
- Mildew/Mold Control
- Glass Cleaner
- Other:
Do you or anybody in your family smoke?
Additional comments?
General Information
Relationship status:
Children:
Pets:
Occupation
Hours of work per week:
Marital Status:
How is your mom's health (if mom is deceased, how was her health throughout her life?
How is your dad's health (if dad is deceased, how was his health throughout his life?
Describe your relationship with your parents:
What is your ancestry?
What is your blood type?
Do you have siblings? If so, how many?
How is their health?
Describe your relationship with your siblings:
Describe the point in your life when did you felt your best:
What were you doing? What kind of clothes did you wear?
Do you have supportive family and friends?
Describe your cravings:
Describe any addictions:
Describe your Childhood Experience:
Describe your Teenage Experience:
Describe your Education & College Experience:
Tell me about your romantic relationships.
Are there any patterns that you can recognize in such relationships?
Have you or someone close to you experienced Alcoholism/Drug Abuse ?
What are your favorite foods?
What percentage of your food is home cooked?
What Foods do you Crave?
Describe your Food Aversion:
Do you have any known food allergies?
Describe your food sensitivities:
How is your Digestion:
Do you experience:
- Acid Reflux
- Constipation
- Diarrhea
- Gas
Is there a family history of asthma?
Women
Do you or have you ever used birth control pills?
Have you had any pregnancies?
Describe your menstrual cycle?
Are you in menopause?
Men & Women Continue Here:
Do you like music?
Do you like to Dance?
How is your life going?
Do you have any recurring dreams?
What are your deepest fears?
Do you have any unusual sensations?
If so, do they occur at any particular time?
Right or left side?
Does climate affect you?
Do you experience moodiness?
Do you have consistent sexual preoccupation?
On a scale of 1-10, how would you rate your sexual relationships.
Please enter a number from 1 to 10.
What is the most important thing you feel you should change about your lifestyle to improve your health?
If you had a theme song, what would it be?
What is your favorite color?
Do you have a favorite number? If so, what?
Is there anything else that you would like to share?
Consent
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