FULL BODY SYSTEMS INTAKE QUESTIONNAIRE PERSONAL INFORMATION
Full Name
Date of Birth
Age
Address (Street, Postal Code, City, Country)
Phone Number
Email Address
PRACTITIONER USE ONLY
r/r
ph
Tong
Notes Practitioner:
GENERAL HEALTH OVERVIEW
1. What would you like to improve about your health or well-being?
3. How long have these concerns been present?
4. How would you rate your overall health (1 = poor, 10 = excellent)?
5. What treatments or therapies have you already tried?
6. What do you hope to gain from this consultation?
7. Most recent blood pressure reading and date (if known):
8. How would you rate your energy level (1 = low, 10 = high)? Score
12. Height
Weight
13. Is there anything else you’d like to share or feel is important?
Appetite, Digestion, Bowel and Hydration
1. Are you hungry at regular times?
2. Daily Food & Drink Intake
Breakfast
Time
What do you eat?
What and how much do you drink?
Any additions to drink like sugar, milk, honey? And how much?
Morning Snack(s)
What?
Drink(s): What and how much?
Any additions to drink like sugar, milk, honey? And how much?
Lunch
Time
What and how much do you drink?
What do you eat?
Any additions to drink like sugar, milk, honey? And how much?
Afternoon Snack(s)
What?
Drink(s): What and how much?
Any additions to drink like sugar, milk, honey? And how much?
Dinner
Time
What do you eat?
What and how much do you drink?
Any additions to drink like sugar, milk, honey? And how much?
Evening Snack(s)
What?
Drink(s): What and how much?
Any additions to drink like sugar, milk, honey? And how much?
Bedtime
How is your sleep?
Wake up with energy?
4. Do you have any food cravings and/or food sensitivities?
5. Other comments on digestion or eating habits:
6. Bowel Movement Frequency
Colour of stool?
10. Bloating or gas?
11. Heartburn, reflux, or belching?
12. Bad breath?
13. Any pain or discomfort in the digestive system?
14. Other comments on digestion:
6. Bowel Movement Frequency
9. Is there undigested food in the stool?
10. Bloating or gas?
11. Heartburn, reflux, or belching?
12. Bad breath?
13. Any pain or discomfort in the digestive system?
14. Other comments on digestion:
Hydration
15. Total Daily Fluid Intake
16. Do you feel thirsty often?
17. Urine
Liver & Gallbladder
Alcohol use (frequency & amount):
Is your right upper part of your abdomen sensitive?
Any pain in the right shoulder?
Hemorrhoids?
Gallbladder issues or fat digestion problems?
Other:
3. Eliminatory Systems
Urinations per day, also at night?
Urine color? Does it smell?
Pain/urgency/incomplete urination?
Water retention/puffiness?
Infection?
Stones?
Other:
Skin
Skin issues (acne, dryness, etc.):
Lungs
Shortness of breath or tightness?
Cough or mucus?
Asthma/allergies?
Dust/smoke/mould exposure?
Other:
Immune System
Frequent illness or infections?
Which body part?
Allergies/sensitivities?
Autoimmune diseases?
Other:
5. Nervous System
Average stress level (1–10):
Anxiety, irritability, overwhelm (scale 1–10) which one:
Depression/mood swings?
Headaches? Migraines?
Jaw clenching?
Dizziness?
Sensitivity to light or sound?
Difficulty sleeping because of thoughts?
Tingling, numbness, muscle weakness, blurred vision, seizures, difficulty with coordination?
Other:
6. Circulatory System
Cold blooded or warm blooded?
Hemorrhoids?
Headaches?
Dizziness?
Blood pressure (high/low)?
Short breath during rest?
Short breath during activity?
Other:
7. Endocrine System
Hormonal diagnoses?
Morning energy level (scale 1–10):
Weight difficulty despite diet? Losing or gaining?
Sugar or caffeine cravings?
Other:
8. Reproductive System
PMS or cycle-related symptoms?
Pregnancy, birth, or miscarriage history?
Fertility concerns?
Menopausal symptoms?
Birth control or hormone therapy?
Other:
9. Musculoskeletal System
General muscle or joint pain?
Muscle stiffness or weakness?
Joint mobility issues?
Past injuries (sprains, fractures, concussion etc.)?
Any muscle pain and where?
Restless legs?
Muscle cramp?
Do you exercise regularly?
What type of movement/exercise?
Other:
10. Lymphatic System
History of infections (mono, EBV, Lyme)?
Detox symptoms (headaches, fatigue, skin eruptions)?
Other:
11. Mental & Emotional Wellbeing
On a scale from 1–10, how happy do you feel on an average day?
On a scale from 1–10, how satisfied are you with your current life situation?
How often do you feel joy, peace, or inspiration?
How often do you feel sadness, anxiety, anger, overwhelm, or numbness? Which?
Are there specific triggers that affect your emotional state (e.g., relationships, seasons, stress, places)?
Do you feel emotionally supported in your life (by people, environment, or practices)?
Do you often suppress or express your emotions?
Thought Patterns
What kinds of thoughts are most often present in your mind?
Are you happy with your current thought patterns?
Would you like to change certain thoughts, beliefs, or inner narratives?
Are your thoughts often influenced by fear, comparison, control, or doubt?
Mindfulness & Mental Clarity
How often do you feel mentally clear and focused?
Do you engage in mindfulness practices (e.g., prayer/meditation, journaling, deep breathing)?
Do you spend time in stillness or silence regularly?
Are you often distracted, overthinking, or stuck in looping thoughts?
Stress & Coping
Do you feel connected to something larger than yourself?
Do you have a sense of purpose or direction in your life?
What brings you meaning or inner fulfillment?
Is there anything blocking your inner peace or emotional growth?
Final Comments
Any comments, thoughts, or things you’d like to add?
Send
