Questionnaire : webnatura a name you can naturally trust

Questionnaire

Patient Health Questionnaire (STRICTLY CONFIDENTIAL)

PHQ

Your Name(required)
Email(valid email required)
Phone(required)
Address(required)
SEX(required)
Age:(required)
Weight:(required)
Height:(required)
Blood pressure:(required)
Pulse rate/min:(required)
Present diseases and complaints:(required)
Past diseases:(required)
Medications (duration, past and present):(required)
Family History:(required)
Vaccinations (lifetime):(required)
Exercises, Sports, Activities & pain and injuries:(required)
Recreation Drugs (marijuana, cocaine, crack, ecstasy, speed, uppers, downers, heroin, etc):(required)
Do you use other types of alternative healthcare or holistic living including chiropractic, acupuncture, massage, colonic irrigation?(required)
Amount of water drank per day: Amount of:(soft drinks/coffee/tea/ beer/wine/mixed drinks/tap water, or bottled water; all measured in 8 oz cups) per day:(required)
Foods eaten (all ingredients) Including all meals and snacks:(required)
Do you have a water filter in house/kitchen/shower?(required)
Do you have an air filter?(required)
Do you have a juicer or wheatgrass extractor? Indicate which, if any.(required)
Do you take vitamin, mineral, protein supplements and if so, what?(required)
Do you get stressed-out often, occasionally or frequently?(required)
Do you have distrust for M.D.’s, D.C.’s or natural healthcare providers?(required)
Do you have any dental fillings of a silver color (amalgam/mercury)?(required)
Do you have any dental pain or problems? If so, what and for how long?(required)
Have you had or have a relationship or childhood experience with slight, moderate or severe abuse (verbal, physical, mental or sexual and at what age?):(required)
Exactly what do you expect to achieve here at Vida Health and Wellness Retreat or with a personal consultation?(required)

DR GAUTIER / WEBNATURA.COM WILL REVIEW YOUR INFORMATION TO CONFIRM THAT THEY CAN BE OF ASSISTANCE TO YOU. UPON COMPLETION OF YOUR EVALUATION THEY WILL EMAIL YOU WITH THEIR ANSWER AND FURTHER INSTRUCTIONS. THIS IS USUALLY DONE WITHIN 24 TO 48 HOURS. THANK YOU.

Questionnaire

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