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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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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?
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