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FULL BODY SYSTEMS INTAKE QUESTIONNAIRE
(To be completed by the client prior to consultation)
Fields marked Required are required.
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Personal Information
Full Name
Date of Birth
Age
Gender
Address (Street, Postal Code, City, Country)
Phone Number
Email Address
Practitioner Use Only
r/r
ph
Tong
Notes Practitioner
General Health Overview
1. What would you like to improve about your health or well-being?
2. Do you have any secondary or related complaints?
Yes
No
3. How long have these concerns been present?
4. Rate your overall health (1 = poor, 10 = excellent)
5. What treatments or therapies have you already tried?
6. What do you hope to gain from this consultation?
7. Most recent blood pressure reading and date (if known)
8. Rate your energy level (1 = low, 10 = high)
9. Are you currently pregnant or breastfeeding?
Yes
No
10. Have you been diagnosed with any conditions?
Yes
No
11. Are you currently taking any prescribed medications?
Yes
No
12. Height
Weight
13. Is there anything else you'd like to share or feel is important?
Appetite, Digestion, Bowel and Hydration
1. Are you hungry at regular times?
Yes
No
2. Daily Food & Drink Intake
Breakfast
Time
What do you eat?
What and how much do you drink?
Additions (sugar, milk, honey?)
Morning Snack(s)
What?
Drink(s) - what and how much?
Additions (sugar, milk, honey?)
Lunch
Time
What do you eat?
What and how much do you drink?
Additions (sugar, milk, honey?)
Afternoon Snack(s)
What?
Drink(s) - what and how much?
Additions (sugar, milk, honey?)
Dinner
Time
What do you eat?
What and how much do you drink?
Additions (sugar, milk, honey?)
Evening Snack(s)
What?
Drink(s) - what and how much?
Additions (sugar, milk, honey?)
Bedtime & Sleep
Bedtime
How is your sleep?
Wake up with energy?
3. Do you feel heavy or sluggish after meals?
Yes
No
4. Food cravings and/or sensitivities?
5. Other comments on digestion or eating habits
6. Bowel movement frequency
7. Stool consistency (check all that apply)
Diarrhea
Soft
Formed like a sausage
Hard Pebble-like/rabbit droppings
Alternating/irregular
Mucous present
Blood present
Sticks to toilet
Floating
8. Stool odor
No strong odor
Rotten eggs
Sour
Sweetish
Pungent
9. Is there undigested food in the stool?
Yes
No
10. Bloating or gas?
Yes
No
11. Heartburn, reflux, or belching?
Yes
No
12. Bad breath?
Yes
No
13. Any pain or discomfort in the digestive system?
Yes
No
14. Other comments on digestion
Hydration
15. Total Daily Fluid Intake
16. Do you feel thirsty often?
Yes
No
17. Urine (color, smell, frequency)
Liver & Gallbladder
Alcohol use (frequency & amount)
Right upper abdomen sensitive?
Yes
No
Any pain in the right shoulder?
Yes
No
Strong body odor/sweat?
Yes
No
Hemorrhoids?
Yes
No
Gallbladder issues or fat digestion problems?
Yes
No
Other
Eliminatory Systems - Kidneys, Bladder & Urination
Urinations per day (also at night?)
Urine color? Does it smell?
Pain/urgency/incomplete urination?
Yes
No
Water retention/puffiness?
Yes
No
Infection?
Yes
No
Stones?
Yes
No
Other
Skin
Skin issues (acne, dryness, etc.)
Sweat easily?
Yes
No
Smell?
Yes
No
Other
Lungs
Shortness of breath or tightness?
Yes
No
Cough or mucus?
Yes
No
Asthma/allergies?
Yes
No
Dust/smoke/mould exposure?
Yes
No
Other
Immune System
Frequent illness or infections?
Yes
No
Which body part?
Recovery speed
Fast
Normal
Slow
Allergies/sensitivities?
Yes
No
Autoimmune diseases?
Yes
No
Other
Nervous System
Average stress level (1-10)
Trouble relaxing?
Yes
No
Anxiety, irritability, overwhelm (scale 1-10) which one?
Depression/mood swings?
Yes
No
Headaches? Migraines?
Yes
No
Jaw clenching?
Yes
No
Dizziness?
Yes
No
Sensitivity to light or sound?
Yes
No
Difficulty sleeping because of thoughts?
Yes
No
Tingling, numbness, muscle weakness, blurred vision, seizures, difficulty with coordination?
Yes
No
Other
Circulatory System
Cold hands/feet?
Yes
No
Cold blooded or warm blooded?
Easy bruising/bleeding?
Yes
No
Varicose veins?
Yes
No
Hemorrhoids?
Yes
No
Headaches?
Yes
No
Dizziness?
Yes
No
Blood pressure (high/low)?
Swelling in extremities?
Yes
No
Chest pain/discomfort?
Yes
No
Palpitations?
Yes
No
Short breath during rest?
Yes
No
Short breath during activity?
Yes
No
Fatigue even after rest?
Yes
No
Swelling in legs/feet?
Yes
No
Other
Endocrine System
Hormonal diagnoses?
Morning energy level (scale 1-10)
Weight difficulty despite diet? Losing or gaining?
Sugar or caffeine cravings?
Other
Reproductive System (Please answer as applicable)
Menstrual cycle regular?
Yes
No
PMS or cycle-related symptoms?
Pregnancy, birth, or miscarriage history?
Fertility concerns?
Menopausal symptoms?
Libido (sex drive)?
Low
Normal
High
Birth control or hormone therapy?
Other
Musculoskeletal System
General muscle or joint pain?
Yes
No
Muscle stiffness or weakness?
Yes
No
Joint mobility issues?
Yes
No
Past injuries (sprains, fractures, concussion, etc.)
Any muscle pain and where?
Restless legs?
Yes
No
Muscle cramp?
Yes
No
Do you exercise regularly?
Yes
No
What type of movement/exercise?
Other
Lymphatic System
Swollen lymph nodes?
Yes
No
History of infections (mono, EBV, Lyme)?
Yes
No
Detox symptoms (headaches, fatigue, skin eruptions)?
Yes
No
Other
Mental & Emotional Wellbeing
On a scale from 1-10, how happy do you feel on an average day?
On a scale from 1-10, how satisfied are you with your current life situation?
How often do you feel joy, peace, or inspiration?
How often do you feel sadness, anxiety, anger, overwhelm, or numbness? Which?
Are there specific triggers that affect your emotional state (relationships, seasons, stress, places)?
Do you feel emotionally supported in your life (by people, environment, practices)?
Do you often suppress or express your emotions?
What kinds of thoughts are most often present in your mind?
Are you happy with your current thought patterns?
Would you like to change certain thoughts, beliefs, or inner narratives?
Are your thoughts often influenced by fear, comparison, control, or doubt?
How often do you feel mentally clear and focused?
Do you engage in mindfulness practices (prayer/meditation, journaling, deep breathing)?
Do you spend time in stillness or silence regularly?
Are you often distracted, overthinking, or stuck in looping thoughts?
Do you feel connected to something larger than yourself?
Do you have a sense of purpose or direction in your life?
What brings you meaning or inner fulfillment?
Is there anything blocking your inner peace or emotional growth?
Final Comments
Any comments, thoughts, or things you'd like to add?
Leave this field empty
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