Once you have booked and paid for your session,
please complete the following “Rx for Success – Assessment Form”
and send back to us so that we may create your personalized
“Prescription for Success”

You can download this form in a PDF file format (445 KB)
(by clicking the PDF icon below),
fill it out and fax it back to us at (905) 985-8043
or you can do this directly on-line.

If you need Adobe Acrobat Reader you can download by clicking on the button


 

Rx for Success - Assessment Form

Please answer each of the following questions. If you require
additional space, use the comments section to write your answers.

Let’s get started!!

Name
Date  
Age
What is your purpose in consulting me?
What are your main health concerns/complaints?
Have you ever been diagnosed with an ailment related to your main
health concerns(s)?
Using the space below please describe any spots of any and all injuries
and complaints?
What level of stress do you feel you are experiencing at this time?
Minimal Average Considerable Unbearable
What are the major causes or factors of your stress? (check all that apply)
Financial Marital Health Unfulfilled Expectations
Spiritual Career Family
Body Image Other Children  
Please elaborate below
How does your stress manifest itself?
How do you want to cope with stress?
How do you actually cope with stress?
How many hours, on average, do you sleep daily? (including naps)
What time do you go to sleep?
Do you awaken feeling rested?
Yes No
What type of work do you do?
Do you enjoy your work?
Yes No Sometimes, Please elaborate
How many hours do you work each day?
At what times do you start and end work?
Do you smoke?
Yes No
If yes, how many cigarettes daily?
If no, does anyone in your household or workplace smoke?
Yes No
What do you do for exercise?
How many times per week do you want to exercise and for how long?
How many times per week do you actually exercise and for how long?
How many hours do you spend, on average, per day:
Driving Watching TV Reading In Front of a Computer
What are your interests and hobbies?
Do you vacation regularly?
Yes No
When was your last vacation? Where did you go?
Do you actively participate in any spiritual discipline?
Yes No
Do you meditate? What type? How often and for how long each time?
Are you:
Married (for how long) Separated Never been Married
Do you have any children?
Yes No
If yes, how many and what ages?
 

MEDICAL HISTORY

 
Have you had, or do you have any of the following?
History of heart problems, chest pains, or stroke Yes No
Increased blood pressure Yes No
Increased blood cholesterol Yes No
Any chronic illness or condition Yes No
Recent surgery (last 12 months) Yes No
Pregnancy (now or within the last 3 months) Yes No
History of breathing or lung problems Yes No
Muscle, joint, back disorder, or any previous injury still affecting you Yes No
Diabetes or thyroid condition Yes No
History of heart problems in immediate family Yes No
Please elaborate
 
Resting Heart Rate Test
 

Sit down with your watch and relax for a few minutes. Now take your
two first fingers (never your thumb) and find your radial pulse at your
wrist or your carotid pulse on the side of your neck. Once you find it,
feel the rhythm, and then count the beats for 30 seconds starting at
zero. Multiply that number by two. This will give you your number of
heart beats per minute. Do this twice so that I can see an average.

 
RHR 1 beats/minute RHR 2 beats/minute
 
Are you currently taking any medication? Yes No
Please elaborate and list reason(s):
Please list any vitamins, minerals, herbal or homeopathic remedies you
are currently taking and the amounts/dosage:
Do you have any allergies? If so, please list:
Have you ever been diagnosed with an illness? Explain
Have you ever been hospitalized? Reason(s)
How often do you have a bowel movement?
Do you strain to have a bowel movement?
Yes No Sometimes
If yes, is it related to a particular food or circumstance?
Do you use any laxatives or suppositories to have a bowel movement?
Yes No Sometimes
Do you have loose bowel movements?
Yes No Sometimes
If yes, is it related to a particular food or circumstance?
Have you ever been treated for a drug and/or alcohol dependency?
Yes No
If yes, please specify which one.
Do you use any ‘recreational” drugs?
Yes No
If yes, how often and what type?
 
FAMILY HISTORY
 
Hereditary Diseases:
 
Use "F" for father, "M" for mother, "S" for sibling, "G" for grandparent
Heart Disease Diabetes Allergies
Hypertension Arthritis Mental Illness
Intestinal Disease Osteoporosis Cancer
Other (please list):
 
FEMALES OVER FORTY
 
Are you pre-menopausal or menopausal?
Yes No
Are you experiencing any symptoms?
Yes No
If yes, please specify:
Have you had a bone density test?
Yes No
If yes, what was the result?
 
DIETARY HABITS
 
How many main meals a day do you eat? Times of day: (enter number)
How many snacks do you eat? Times of day: (enter number)
 
How many ½ cup servings do each do you typically eat in a day:
Fruit: fresh Dried Canned
Vegetables: Cooked Raw
Whole Grains
Protein: Type
Dairy Products: Type
 
What would you want your typical breakfast to be?
What would your typical breakfast actually be?
What would you want your typical lunch to be?
What would your typical lunch actually be?
What would you want your typical dinner to be?
What would your typical dinner actually be?
What would you want your typical snacks to be?
What would your typical snacks actually be?
 
Do you eat or use (indicate “1” for “rarely”, “2” for “regularly”, “3” for “often”):
Aluminum Pans Margarine Candy
Microwave Fried Foods Refined/Processed Foods
Luncheon meats Cigarettes  

Nutra-Sweet/aspartame

   
 
Please indicate how many cups of the following you drink per day:
Coffee White Wine
Tea Red Wine
Herbal Tea Beer
Diet Soft Drinks Other alcoholic beverages
Regular Soft Drinks Tap water
Prepared Fruit Juices Bottled or Spring Water
Milk (1% or 2%) Fresh Fruit Juice
Homogenized Milk Fresh Vegetable Juices
Milk (skim) Other
 
Are you a: Meat eater? Vegetarian? Vegan?
How often do you eat red meat?
Daily 3-5 x per Week Once a Week or Less
How often do you consume dairy products?
Daily 3-5 x per Week Once a Week or Less
What are your favorite foods?
How often do you eat them?
Do you avoid certain foods? If so, why?
Do you experience any symptoms if meals are missed? Explain:
Do you experience any symptoms after meals? Explain:
If any of the following symptoms or activities have occurred within the past three months, please indicate by checking:
• "1" for mild or rarely occurring
• "2" for moderate or regularly occurring
• "3" for severe or often occurring or
• "leave blank" if the symptom/statement does not apply
 
1. General Fatigue or Weakness
2. Difficulty Losing Weight
3. Frequent Illness/Infections
4. High Stress Lifestyle
5. Smoking
6. Drink more than 2 cups of Coffee/day
7. Bad Breath and/or Body Odor
8. Constipation
9. Bags Under Eyes
10. Crave Sugars, Bread, Alcohol
11. Difficulty Digesting Certain Foods
12. Have Used Antibiotics in Past 10 Years
13. Allergies
14. Poor Concentration or Memory
15. Belching or Burping after Meals
16. Skin/Complexion Problems
17. Frequent Consumptions of Red Meat
18. Regular Use of Dairy Products
19. Heavy Alcohol Consumption
20. Exposure to Toxins/Chemicals
21. Frequent Mood Swings
22. Depressed and/or Irritable
23. Brittle Fingernails
24. Dry, Brittle Hair, Split Ends
25. High Fat/High Cholesterol Diet
26. Nervousness/Anxiety/Tension/Worry
27. Insomnia/Restless Sleep
28. Low Fiber Diet
29. Muscle Cramps
30. Sleepy when Sitting Up
31. Female: Menstrual Cramps
32. Bronchitis/Asthma/Pneumonia/Emphysema
33. Cellulite
34. Cold Hands and Feet
35. Varicose Veins
36. Feeling out of Control
37. Food/Chemical Sensitivities
38. Frequent Yeast/Fungus Problems
39. Bones Break Easily, Osteoporosis
40. Too Little Exercise
41. Excessive Mucous
42. Shortness of Breath Climbing Stairs
43. Tingling in Lips, Fingers, Arms, Legs
44. Chest Pains
45. Very Rapid or Slow Heart Beat
46. Painful, Hard or Thin Bowel Movements
47. Alternating Constipation/Diarrhea
48. Recurrent Bladder Infections
49. Female: Menopause, Hot Flashes
50. Female: PMS
51. Difficult Urination
52. Swollen Glands, Puffy Throat
53. Lower Abdominal Pain
54. Frequent Need to Urinate
55. Joint Pain
56. Sinus Inflammation/Discharge
57. Arthritis
58. Sudden Weight Gain/Loss
59. Headaches/Migraines
60. Female: Taking Birth Control Pills
61. Lower Back Pains
62. Dry, Flaky Skin
63. Drink Less than 6 Glasses of Fluids/Day
64. Water Retention
65. Low Sex Drive
66. Feeling Heavy/Bloated After Meals
67. Chronic Cough
 
Please provide me with any other information that you feel is imperative for me to know – past or present – that may influence your “Rx for Success”
 
Client Statement
 

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment, or prescribing of medicine for any disease, or any licensed or constitute the practice of medicine. This statement is being signed voluntarily.

 
Signature: (Type in your name)
Address:
City:
State/Province:
Zip/Postal Code:
Email:
Telephone: ie: 555-555-5555
Home
Cell
 
Comments


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