Wellness Questionnaire - Seton Health
Wellness Questionnaire - Seton Health
Wellness Questionnaire - Seton Health
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<strong>Wellness</strong> <strong>Questionnaire</strong><br />
What is the purpose of your visit today?<br />
•Reclaim <strong>Health</strong>y Lifestyle •Optimal <strong>Health</strong> •Increased Sense of Wellbeing •Weight Loss<br />
Tell Us About You<br />
Name (First-Middle-Last) _____________________________________________________<br />
Date of Birth _______________________________________________________________<br />
Street Address______________________________________________________________<br />
City______________________________________________________________________<br />
State_____________________________________________________________________<br />
Zip_______________________________________________________________________<br />
Phone (home)_________________ (work)_________________ (cell)__________________<br />
E-mail_____________________________________________________________________<br />
Primary Care Physician _______________________________________________________<br />
How did you hear about us? ____________________________________________________<br />
___________________________________________________________________________<br />
What are your expectations? ___________________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
How important is maximizing your health? ________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
What are you currently doing to reach your health potential? __________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
Physical Assessment<br />
Do you have any physical complaints? _____ If yes. . . tell us more<br />
Brief description of symptoms___________________________________________________<br />
___________________________________________________________________________<br />
How long ago did symptoms begin? ____________ Is this a recurring problem? ___________<br />
How do these symptoms limit you? ______________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
What makes the symptoms worse? ______________________________________________<br />
What makes the symptoms better? ______________________________________________
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<br />
Please check any of the following you have had in the last six months:<br />
Muscular-Skeletal General Male/Female<br />
__ Low Back Pain __ Fatigue __ Menstrual Irregularity<br />
__ Pain between shoulders __ Allergies __ Thyroid Disorder<br />
__ Neck Pain __ Depression __ Fibromyalgia<br />
__ Arm Pain __ Difficulty Sleeping __ Prostate<br />
__ Joint Pain / Stiffness __ Chronic Pain __ Lack of Energy<br />
__ Walking Problems __ Weight Issues __ Bladder Infections<br />
__ Jaw Pain / Clicking<br />
__ Mood Swings<br />
__ Auto Accident<br />
<br />
Nervous System<br />
Cardiovascular<br />
__ Nervous<br />
__ High Blood Pressure<br />
__ Irritability<br />
__ High Cholesterol<br />
__ Headaches<br />
__ Shortness of Breath<br />
__ Dizziness<br />
__ Difficulty Breathing with exertion<br />
__ Forgetfulness<br />
__ Stress<br />
Are you taking any medications? ___ If yes, what are you taking _______________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
Are you taking any nutritional supplements?___ If yes, what are you taking______________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
Are you currently dieting? ___ If yes, what program are you doing? ____________________<br />
Have you had a check up in the last 6 months? _____________________________________<br />
Are you seeking care on a routine basis ___________________________________________<br />
What specific goals would you like to achieve with this program? _______________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
Is there any additional information you would like to share? ___________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
___________________________________________________________________________
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