Health Questionnaire

Kindo Center Health Questionnaire

Please take a moment to complete this questionnaire. Include your contact information if you would like to be contacted for a consultation.

Disclaimer: Kindo Center agrees that the information gathered here is to be considered confidential and proprietary to you, and Kindo Center shall hold this information in confidence, shall not use the information other than for the purposes of potential health services for you. Kindo Center will not disclose, publish or otherwise reveal any of your information to any other party whatsoever except with your specific prior written authorization.

I prefer to respond anonymously:

No Yes

Name

E-mail

Today's Date [DD/MM/YYYY]

Date of Birth [DD/MM/YYYY]

Place of Birth

Enter where you were born (e.g. city, state, country)

If you are under 18, please enter the name of your parent or guardian.

Current Address

City

State

Zip Code

Enter your home phone number.

Enter your work phone number.

Enter your mobile phone number.

Select the item that best describes your relationship status.

Single and living alone
Single and living with partner
Married

Do you have any children?

Select if you have one or more children.
Yes
No

Enter the names and ages of your children.

Your Occupation

Enter the name of the person (or source) that referred you to Kindo Center.

Primary Health Concern

Please include, briefly, the location of the health issue, time of onset, cause (if known), factors that aggravate your symptoms, and any other pertinent information.

Secondary Health Concern

Please include, briefly, the location of the health issue, time of onset, cause (if known), factors that aggravate your symptoms, and any other pertinent information.

Please list all medications that you are currently taking. Include both natural medicines (eg. herbs, homeopathic, vitamin supplements, etc.) and prescription drugs.

Are you currently being treated by a medical doctor?

Yes
No

If yes, please enter the name of the medical doctor and city.

Are you currently being treated by a chiropractor?

Yes
No

If yes, please enter the name of the chiropractor and city.

Are you currently being treated by a naturopath?

Yes
No

If yes, please enter the name of the naturopath and city.

Are you currently being treated by an oriental medicine specialist?

Yes
No

If yes, please enter the name of the oriental medicine specialist and city.

Are you currently being treated by another type of health care provider?

Yes
No

If yes, please enter the name of the other health care provider and city.

What is your blood type?

How would you rate your current level of health? [1 = Very Poor, 10 = Excellent]

How would you rate your current level of energy? [1 = Very Poor, 10 = Excellent]

Energy Levels

Are you fatigued, or do you fatigue easily?
Do you need to take naps?
Do you generally feel cold?
Do you have cold feet or hands?
Do you ever have low grade fever?
Do your hands and feet warm up easily?
Do your feet get warm at nighttime, in bed?
Do you ever wake up sweating during the night?
Men: Do you have ejaculations during your sleep?

Appetite and Taste

Has your appetite altered recently?
Do you have a poor appetite?
Do you have poor digestion?
Do you have epigastric (stomach) distention?
Do you have abdominal (large intestine) distention?
Are you experiencing belching?
Are you passing gas?

Diet

What percentage of your diet is animal protein?

Diet

What percentage of your diet is vegetables?

Diet

What percentage of your diet is carbohydrates (Bread, Rice, Pasta)?

Diet

What percentage of your diet is fruit?

Diet

What percentage of your diet is sweets?

List any known or suspected food allergies.

Thirst and Dryness

Do you have dry eyes?
Yes
No

Thirst and Dryness

Do you have a dry nose or lips?
Yes
No

Thirst and Dryness

Do you have a dry skin or hair?
Yes
No

Thirst and Dryness

How many glasses of water or fluids do you drink daily?

Stools and Urine

Are your stools:
Normal? (Daily with same shape and size.)
Unusually hard?
Unusually loose?
Erratic in form? (Sometimes hard, sometimes loose.)

Stools and Urine

Do you have bowel movements less than five times a week (constipation)?
Yes
No

Stools and Urine

Is there any blood or pus in your stool?
Yes
No

Stools and Urine

Do you have hemorroids?
Yes
No

Stools and Urine

Is your urine:
Unusually scanty and dark?
Unusually profuse and clear?

Stools and Urine

Do you wake more than once a night to urinate?
Yes
No

Stools and Urine

Do you experience any dribbling of urine?
Yes
No

Stools and Urine

Do you have urgency to urinate?
Yes
No

Stools and Urine

Do you experience burning urination?
Yes
No

Sleep

Do you suffer from insomnia?
Yes
No

Sleep

Do you have restless sleep?
Yes
No

Sleep

Do you have uncomfortable dreams?
Yes
No

Emotions

Structure

Do you suffer from chronic or occasional backache or neck ache?
Yes
No

Structure

Do you suffer from chronic or occasional joint pain?
Yes
No

Structure

Do any muscles ache or cramp?
Yes
No

Accidents

Please list all major accidents, including fractures, deep cuts, serious sprains, etc. Please indicate all head injuries. Include dates or age.

Surgery History

Describe reason, age, and any consequential outcome.

Surgery History

Have you ever had a blood transfusion?
Yes
No

Surgery History

If so, what year?

Exercise

What do you do for exercise? How often?

Disease History

Do your parents have any unusual health problems? If they died, state cause of death and age of death.

During your mother’s pregnancy with you, did she:

Please describe any other serious illness, injury, or complaint.

Please indicate whether you had any of the following in the past.

Please indicate whether you currently have any of the following.

If you answered yes to hepatitus, please enter the type.

If you answered yes to parasites, please enter the type and date.

Drug History - Past

Drug History - Present

Women Only

If you answered yes to breast implants, did you have them removed? When?

Women Only

If you answered yes to hysterectomy, what year?

Women Only

If you said yes to using a birth control method, past or present, please specify the number of years usage.

Women Only: Menstrual History

Select all that apply.
I am currently pregnant.
I am presently suffering from a menopausal disorder.
I have completed menopause.
My periods are painful.
My ovulation is painful.
I bleed excessively.
I bleed too little.
I discharge clots.
I get headaches during menstruation or ovulation.

Women Only: Menstrual History

If your period is regular, specify how many days between periods and how many days your period lasts.

Women Only: Menstrual History

If you suffer from premenstrual syndrom (PMS), please select all that apply.
Irritability
Breast distention
Headache
Water retention

Women Only: Menstrual History

How many days before your period do the PMS symptoms begin?

Women Only: Pregnancy History

How many times have you been pregnant?

Women Only: Pregnancy History

If have have had any abortions, how many?

Women Only: Pregnancy History

If you have had any miscarriages, how many?

Women Only: Pregnancy History

Select if you have had an ectopic pregnancy.
Yes
No

Women Only: Pregnancy History

Select if you have had difficulty following childbirth.

Yes
No