The Applied Kinesiology Center
Comprehensive Form
Confidential Health Questionnaire
Name__________________
Date___________
Mark severity in past/now box from 1 to 3. (1-slight 2-moderate 3-severe)
please check box ( ) where appropriate.
Statistics:
Height:
Weight: now:
; one year ago:
;maximum:
when?
Surgery: ovaries/uterus ( ) gallbladder ( ) appendix ( ) other ( )
Have you ever had X-rays of: back ( ) neck ( ) extremities ( ) organ ( )
other ( )
Have you ever had a MRI/CTScan?
Favorite Foods:
Allergies: Food or other:(list)
What foods do you crave and when?
Do You Use….
Never Rarely Freq.
Daily
Vitamins
Laxatives
Sedatives/tranquilizers
Sleeping pills/Aids
Aspirin, etc.
Appetite drugs:
Alcoholic Beverages
Coffee/Tea cups per day:
Soft Drinks
Cigarettes packs per day:
Cigars/Pipes ( ) Chewing tobacco ( )
Recreational Drugs: Marijuana ( ) Other ( )
Have you EVER tried any recreational drugs?
Current Supplements/Medications (List)
Medications:Please include: Name/Reason for taking/Duration:
Vitamins/Minerals/Herbs:(list)
Part One: Musculo-Skeletal & Nervous System
Past
Now
Muscles:
Sore ( )
aching ( )
weak ( )
tight ( )