Health Questionnaire
Please describe conditions as fully as possible, indicating what makes it better (other than drugs) or worse – e.g. rubbing, heat, noise, light, lying, standing, weather, temperature.
Try to give dates and duration of any current or past physical and emotional problems so that a healing time line can be established.
All information is strictly confidential. If you are unhappy about giving precise details about certain events or problems in your life, it is helpful if you can indicate the type of emotion experienced at the time - e.g. anger, fear, grief.
Please ensure you answer every section and try to avoid words such as usual or normal
Any child under the age of 16 years must have this questionnaire authorised by their parent or guardian*.
Personal Details
| Name | |
| Date of Birth | |
| Address 1 | |
| Address 2 | |
| Address 3 | |
| Post code | |
| Country | |
| Telephone No | |
General Health Details
| Occupation | |
| Hobbies / sports | |
| Smoker | |
| Alcohol consumption | |
| Presenting condition | |
| Date of first symptoms | |
| Medical treatment | |
| Current medication | |
| Past medication | |
| Vaccination history | |
Medical History
| Headaches - Where, when, description of pain |
|
| Scalp or hair problems | |
| Eyes / Sight -
Glasses, discharges, dryness, |
|
| Ears / Hearing -
Discharges, pain, sounds |
|
| Nose / Sense of smell -
Discharges, sinuses, hay fever |
|
| Mouth / Taste -
Gums, tongue and coating, ulcers |
|
| Throat / Voice
Problems or sensations |
|
| Breathing / Chest -
Asthma, pain, sighing, yawning |
|
| Heart / blood pressure -
Palpitations, high / low BP |
|
| Appetite / Sensitivities -
Cravings, aversions, foods which aggravate |
|
| Typical days diet (be honest!)-
Breakfast Lunch Dinner Snacks |
|
| Drinking habits -
Thirst and preferred drinks |
|
| Digestion -
Indigestion, heartburn, burping, pain |
|
| Bowels motions -
Frequency, hard/soft, colour, smell Flatulence, bloating, piles, itching |
|
| Urine -
Smell, colour, frequency, pain |
|
| Sexual organs / libido / thrush-
Any discharges, soreness, pain |
|
| Menstruation / PMT -
Frequency, duration, flow, pain, |
|
| Pregnancy History | |
| Breasts | |
| Extremities / movement
Aches/ pains in arms, legs, back, neck |
|
| Condition of nails | |
| Skin / eruptions -
Dry, itchy, greasy, eczema, acne, boils |
|
| Sleep Pattern / dreams -
Getting to sleep, sleep: sound / restless |
|
| Environmental effects -
Heat/cold, damp/dry, drafts, sun, open air, light, noise |
|
| Emotional -
Angry / irritable or emotional / weepy Anxieties, fears, phobias Confidence level Past emotional upsets, traumas, deaths etc. and responses to them |
|
| Traumas -
Past operations, illnesses, Accidents and responses to them. |
Declaration
| Name | Signed | ||
| Date | *Guardian |
The above information is believed to be an accurate description of my current health. If client is under 16 years of age this must be signed by a parent or guardian.
Please send this questionnaire with a cheque for £45 in UK pounds sterling made payable to Cyla K. Higley
Results and remedies will normally be despatched within 10 working days.
The hair test is designed to help you to identify and then assist you in resolving the root cause of your problem which also gives you back control over your health.
What will you receive?
Depending on your condition, using a kinesiology test to help your hair analysis, you may receive information relating to a basic food sensitivity test, vitamin and mineral requirements, organ imbalance, homeopathic remedies, Bach flower requirements, suggestions for structural corrections and chakra requirements.
The hair test allows everyone to receive a specific, individual and holistic treatment suggestion.
A variety of Natural Therapies may be suggested
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