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Total Health Programme Questionnaire

Please submit this form and a free consultation will be scheduled.
About the Total Health Programme.

Name:
Address:
Postcode:
Phone number/ Mobile:
Email:
Date of birth:
What is your weight?	stone lbs.
What is your height?	feet inches
Occupation:
Hobbies/Recreation:
How did you hear about the Westoe practice?
Please list previous/current illnesses/accidents/surgery that you have had:
Please list any medication you are currently using:
Please list the health problem(s) you would like to resolve:
Do you regard your health problem(s) to be;	Severe Moderate Mild
What other forms of therapy have you used to resolve your health problem (s)?
How successful were they?	Very successful Partly successful Not successful
Please list any supplements you are currently taking (Vitamins, minerals, fatty acids, amino acids, antioxidants etc):
What is your daily water/herbal tea intake? (not including fruit juices, soft drinks, tea, coffee, alcohol)	2.5 litres 2 litres 1 litre 500ml or less
Briefly describe your diet:
On average how much alcohol do you drink in a week?
Are your bowel movements:	Daily Less than daily Other
How often do you exercise?	Daily Weekly Occasionally Never
On a scale of 1 to 10 what is your energy level?	1 2 3 4 5 6 7 8 9 10
Do you smoke cigarettes? If so how many per day?
Do you use orthotic appliances in your shoes?	No Yes
Do you wear a pace maker?	No Yes
If you are female: Are you pregnant?	No Yes
If yes, how advanced?
In what way do you expect your health problem(s) to improve with natural therapies?
Do you have any other goals or concerns? If so please briefly explain:
Please tick all boxes that apply to you. These might reflect your current state of well being or your desired outcome. Place two ticks against those you would like to resolve or improve; Abandonment Acid indigestion Acne ADHD Ambition Ankle pain Athletic conditioning Allergies Anxiety Arthritis Asthma Autistic spectrum disorders Breathing difficulties Bronchitis Bloating & wind Behavioural difficulties Candida (Yeast overgrowth) Cancer Career choices Chakra Imbalances Chronic Fatigue Syndrome (Formerly ME) Concentration difficulties Confidence problems Constipation Demotivated Depression Desiring change Detoxification Diet (Difficulties sticking to or food cravings) Digestion problems Digestive health Dyslexia Ear, nose and throat problems Electro- magnetic stress Emotional problems Enemies Energy imbalances Exercise Eczema Fatigue Fears Fertility Fibromyalgia Financial concerns Flatulence (Wind or gas) Fluid retention Foot problems Frozen shoulder Guilt Gas or wind Grief Hay fever Healing Heartburn Heel pain Hip pain Hormonal imbalance Hypnobirthing Impotence Indecisiveness Insomnia Infertility Inferiority Intrusive thoughts Joint pains Joint and muscle stiffness Knee pain Lack of clarity Letting go Leg length discrepancies Learning difficulties Loneliness Low self esteem Low energy Low immunity ME Menopausal symptoms Menstrual problems Mental health Migraine Motivation and direction Mouth ulcers Movement Muscle tension Nail infections Neck pain Negative thoughts Nervousness Nutrition Overwhelmed Obsessive compulsive disorder Pain Positive approach to life Posture Pregnancy health Pre menstrual tension or syndrome Phobias Pronation Psoriasis Regrets Relationship problems Repeated infections Rheumatism Sadness Self Image Self esteem Separation Sexual problems Shyness Skin problems Sleep problems Smoking Spiritual healing Spiritual guidence Spiritual growth Sports conditioning Stomach pains Stress Strength Suicidal thoughts Temper Tennis elbow Tension Tiredness Unhappiness Unpleasant memories Water retention Negative beliefs (Negative or harmful thoughts) Weight issues Addictions Anger Back pain Childhood trauma Cystitis Diarrhoea Dyspraxia Fat loss Fat loss Fitness training Calming Energy Fungal infections Headaches Holistic Beauty Indigestion Irritable Bowel Syndrome Legal matters Limiting beliefs Memory problems Mood swings Muscle weakness Nurturing Personal Development Panic attacks Relaxation Sciatica Shoulder problems Socialising skills Sports nutrition Suppination Thrush (Vaginal & oral) Work