Confidential Client Health Questionnaire (CCHQ)

Name *
Name
Address *
Address
Best Phone Number *
Best Phone Number
Date of Birth *
Date of Birth
Children?
Health
Do you sleep well?
Do you drink caffeinated beverages?
Do you smoke?
Are you currently under a practitioner's care for a specific health issue?
Do you crave...
Please select all that apply
Do you feel tired, bloated, and/or gassy after meals?
Please select all that apply
Do you experience constipation or diarrhea?
Do you feel excessively hungry, or have a poor appetite?
Family health history
Family Health History
Do you have any of the following conditions in your family? Please indicate all that apply
Please indicate what type of cancer, or "other" or additional information about the above conditions
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
WOMEN ONLY
Menstrual Cycle
Are your periods regular?
Do you experience PMS?
Date of your last period
Date of your last period
Pregnancy
Have you been, or are you currently pregnant?
History of miscarriages or abortions?
Did you receive antibiotics during labor?
Menopause/Peri-menopause
Are you peri/menopausal?
Miscellaneous
Do you enjoy daily activities?
Do you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc.?
Do you feel your libido is adequate:
Would you like to discuss women’s heath issues specifically?
MEN ONLY
Do you wake at night to urinate?
Do you have any difficulty and/or pain with urination?
Do you have diminished flow?
Do you enjoy daily activities?
Do you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc.?
Do you feel your libido is adequate:
Do you feel less assertive in daily life than previously?
Would you like to discuss men’s health issues specifically?