New Client Questionnaire

(If you are under 18, it will be required that all custodial parents or guardians join DPNWA.ORG prior to your scheduling your appointment.This can also be done in person at the office on a membership document if both parents are present.)


Please list any diagnoses you have received and when you were diagnosed to the best of your recollection. (This is voluntary. If you only wish to discuss these verbally without a written record this is acceptable.)


All of the following information is voluntary. If you do fill this out your privacy will be protected and this will not be shared with anyone outside of Natural Health Sciences of Arizona without your consent. If you are seeking natural medicine from Natural Health Sciences of Arizona for some relatively simple health issues that can be easily explained verbally you can opt out of this lengthy questionnaire altogether and just discuss these on your scheduled apt. If you are dealing with more complex issues and have a new apt of 2 hours or more, filling this out saves valuable apt time and money for you.


What brought you here?


Please list any medical diagnoses you have received and when you were diagnosed to the best of your recollection: (This is voluntary. If you only wish to discuss these verbally without a written record this is acceptable.

Please list your symptoms, starting with the ones that are most severe and affecting quality of life. Be specific. Ie. severe fatigue, knee pain, insomnia. List them according to priority. List as many as you wish. Ask family members if you can't think of any. (Please avoid subjective statements like, “I think I have parasites in my gallbladder”. Use purely symptom statements such as, “I have a sharp pain under my right rib cage, especially when I eat certain things.”)

Now that you have listed your symptoms here are some lifestyle questions to help us get a better idea of your overall condition.


EXERCISE- What is your current level of exercise if any? How much, what kind?

DIET- Are you following any diet philosophy such as Paleo, Vegan, GAPS, Bulletproof, Gerson, GFDF, Raw, etc.?

List the foods (including junk foods) that make up the bulk of your diet, including staple foods that provide the majority of your calories.

Are there foods that you avoid either because of symptoms or other reasons?

How well do you think your digestion works and do you have normal, formed, regular bowel movements?


YesNo


YesNo


YesNoSOMETIMES


YesNoSOMETIMES


YesNoSOMETIMES

Anything else that could affect your ability to follow through with a natural protocol?


Questions about medical and dental issues.


Do you have anything implanted in your body, cosmetic or structural and if so, do you know what material it is made out of?


YesNo

Do you have root canals? If so, please find out which teeth if possible.

 

If you have ever had any surgeries, please list these and about when.

If you have ever had any serious injuries, please list these.

Please list any prescription medications you are taking.

Please list any medical treatment you have done in the past or are currently doing to try and get well.

What was the outcome of these? Did they help you or harm you based on your experiences?


Natural supplements or equipment.


Please list any herbal, nutritional or other supplements you are taking. (Note: If you have scheduled an initial appointment 3 hours or longer you do not need to list these, you will bring them to your appointment to be evaluated there.) If you have a shorter appointment and/or you do not bring your supplements then list here. You can also take photos of supplement labels with complex ingredients for your appointment.)

Are there any natural products that you feel made you worse?

Do you still have any natural therapy equipment at home that we could use in getting you well? What is it? You may take photos for your appointment.


Mental approach assessment.


How serious are you about getting well?

Are you fighting hard to get well but are also impatient with the process? And also do you constantly and rapidly change your natural therapies and treatments all the time?

Are you apathetic such that family members or friends care more about your health and recovery than you do? Or is the opposite true? In other words, does your family express concern with your excessive focus on health?

Deep down do you feel helpless and that regaining your health is impossible or at least extremely unlikely because you feel nothing you do can make a difference?

Are you extremely fearful of the illness you are battling and symptoms of it, and fearful about all treatments, natural or medical? In other words, are you afraid almost any natural therapies you do might make you worse, will have a bad outcome?

Do you understand that the body can induce a healing crisis at times as you move toward wellness and that this can be uncomfortable? Would you always discontinue any new product or method at the first sign of discomfort feeling that it is hurting you? (This is not meant to imply that ALL beneficial products or therapies induce symptoms, or that serious symptoms should be ignored. My own experience with recovery was that some of the most beneficial things caused strong healing reactions, but these did not last very long and were accompanied by an improved sense of well-being.)

Do you often do things that could sabotage your efforts to get well, eg., eat sugar, or junk, or smoke? In other words, do you have the self-discipline to control things that could sabotage your recovery efforts?

Are you more interested in enjoying the moment than doing the hard work to get well?

Do you have so much brain fog and personal disorganization that following an orderly protocol throughout the day would be difficult or impossible? If so, do you have a caretaker that could do it for you?

Are you extremely angry about your health, or angry with your body?

Are you angry over lack of support from family or others to help you get well?

Do you feel guilty that the illness you are struggling with prevents you from working, contributing, or causes loss of resources or hardship to those you love?

Do you have humility to learn from others through this process of recovery or do you think you already have all the answers, or most of them?


Final questions.


Do you have any known allergies to foods, supplements, medications or other substances?

Do you have any history of drug or substance addiction treated or untreated, or currently an active addiction that needs to be taken into consideration?



Thank you. Doing this in advance saves you valuable appointment time and money. It allows us to gain the best usage of your time with us.

Important: By sending this form you are agreeing that you are a current member of Desert Paths Wellness Association. (DPNWA.ORG)
 

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  • If you answered "dependent" please answer the questions as you would if you were speaking for them in the first person.
  • (If you are under 18, it will be required that all custodial parents or guardians join DPNWA.ORG prior to your scheduling your appointment.This can also be done in person at the office on a membership document if both parents are present.)

  • Your privacy is important to us and any information voluntarily given here will be stored on a secure data server and will not be shared outside of Natural Health Sciences of Arizona without your consent. If you are seeking natural medicine from Natural Health Sciences of Arizona for relatively simple health issues that can be easily explained verbally, you can opt out of this lengthy questionnaire altogether and just discuss these on your scheduled apt. If you are dealing with more complex issues and have a new apt of 2 hours or more, filling this out saves valuable apt time and money for you.

  • What brought you here?

  • Please list your symptoms, starting with the ones that are most severe and affecting quality of life. Be specific. Ie. severe fatigue, knee pain, insomnia. List them according to priority. List as many as you wish. Ask family members if you can't think of any. (Please avoid subjective statements like, “I think I have parasites in my gallbladder”. Use purely symptom statements such as, “I have a sharp pain under my right rib cage, especially when I eat certain things.”)

  • Now that you have listed your symptoms here are some lifestyle questions to help us get a better idea of your overall condition.
  • Questions about medical and dental issues.

  • Natural supplements or equipment.

  • Mental approach assessment.

  • Final questions.

  • Thank you. Doing this in advance saves you valuable appointment time and money. It allows us to gain the best usage of your time with us.


    Important: By sending this form you are agreeing that you are a current member of Desert Paths Wellness Association. (DPNWA.ORG)