Client Assessment Form

NOTE: If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring / 2 for moderate or regularly occurring / 3 for severe or occurring all the time.

Please leave blank if the symptom/statement does not apply.

symptoms or activities

General fatigue or weakness

Difficulty losing weight

Frequent illness/infections

High stress Lifestyle


Drinking more than 2 cups of coffee/day

Bad breath and/or body odour


Bags under eyes

Crave sugars, bread, alcohol

Difficulty digesting certain foods

Have used antibiotics in past 10 years


Poor concentration or memory

Belching or burping after meals

Skin/complexion problems

Frequent consumption of red meat

Regular use of dairy products

Heavy alcohol consumption

Exposure to toxins/chemicals

Frequent mood swings

Depressed and/or irritable

Brittle fingernails

Dry, brittle hair, split ends

High fat/high cholesterol diet


Insomnia/restless sleep

Low fibre diet

Muscle cramps

Sleepy when sitting up

Female: menstrual cramps



Cold hands and feet

Varicose veins

Feeling out of control

Food/chemical sensitivities

Frequent yeast/fungus problems

Bones break easily, osteoporosis

Too little exercise

Excessive mucous

Short of breath climbing stairs

Tingling in lips, fingers, arms, legs

Chest pains

Very rapid or slow heart beat

Painful, hard or thin bowel movements

Alternating constipation/diarrhea

Recurrent bladder infections

Female: Menopause, hot flashes

Female: PMS

Difficult urination

Swollen glands, puffy throat

Lower abdominal pain

Frequent need to urinate

Joint pain

Sinus inflammation/discharge


Sudden weight gain/loss


Female: Taking birth control pills

Lower back pains

Dry, flaky skin

Drink less than 6 glasses of fluids/day

Water retention

Low sex drive

Feeling heavy/bloated after meals

Chronic cough