New Client Questionnaire

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home phone

(###)

###

####

Mobile phone

(###)

###

####

Date of birth

MM

DD

YYYY

Have you ever taken antibiotics?

Yes

No

Have you ever taken birth control?

Yes

No

Not applicable

Have you ever been on hormone replacement therapy?

Yes

No

Are you pregnant or currently trying to conceive?

Yes

No

Do you consume coffee?

Yes

No

Do you consume tea?

Yes

No

Do you consume alcohol?

Yes

No

Is it restful?

Yes

No

Are you under a lot of stress at work?

Yes

No

Are you under a lot of stress at home?

Yes

No

Do you practice any stress reducing techniques?

Yes

No

Do you exercise regularly?

Yes

No

Do you or have you used recreational drugs?

Yes

No