Acupuncture Clinic Toronto
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Direct insurance billing available for
MASSAGE THERAPY

SHIATSU

REFLEXOLOGY

ACUPUNCTURE




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416-929-6958


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Diet/Lifestyle Questionnaire


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Confidential Patient Case History: Health, Diet and Lifestyle Chart

Date: 

Name:

 
Height:  
Weight:  
Sex  

Please list the main reasons why you seek a Health and Nutritional Consultation

Have you noticed any significant increase in your appetite over the last 5 years?
If so, please describe briefly:

How difficult is it for you to avoid over eating? (0=none 10=maximum):
1 2 3 4 5 6 7 8 9 10
Do you have any cravings? If so, for what? :
How difficult is it for you to control your cravings for certain foods?
1 2 3 4 5 6 7 8 9 10
Please indicate the level of your stress on the scale below:
1 2 3 4 5 6 7 8 9 10
On a scale of 1 to 6, where 1 means no resistance to your eating desires (eating whatever you want, whenever you want it) and 6 means total restraint (always limiting food intake and never "giving in"), what number would you give yourself?
How often do you have a bowel movement?
Do you feel bloated after almost every meal?
If you have bloating, what usually makes it worse?
Approximately what times of the day does the bloating get worse?
Is your bloating usually worse before or during periods? (females only)
Which part of your abdomen becomes distended immediately after a heavy meal
If you have been suffering from mental/emotional stress, please indicate briefly:
Are you regularly practicing some form of breathing exercise?
If so, please describe the type of breathing exercise and how long you have been doing it
Do you do any exercise on a regular basis? If so, describe what exercise, duration, how often, for how long:
If you are interested in weight loss, please indicate the reason(s) why you want to lose weight:
If you have a particular part of the body you would like to shape up please indicate:
Have you ever tried any weight loss programs before? If so, describe what kind, when, with what result:
Please list the current and previous treatment (conventional and alternative) information for your health concern(s). List practitioner's name, treatment, result:
What type of water do you drink?
Do you have a water filtration system in your house or office? If so, please describe:
Do you regularly take vitamins, mineral, herbal or nutritional suplements:  
If so, please describe:
Name/Type of supplement Brand name No. of Tablets per day Dose per tablet Reason for taking Recom-mended by
Using the table below, please describe your typical diet for the past 6 months
Day Meal -> Before breakfast Breakfast Between Lunch Between Dinner After dinner
1 Food
Beverages
2 Food
Beverages
3 Food
Beverages
4 Food
Beverages
 
Weight History Chart
(from age of 15 to the present)
Age (years) Weight (lbs.)
15
20
25
30
35
40
45
50
55
60
65
70
Weight History Chart
(for the last year)
Month Weight (lbs.)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec

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The Pacific Wellness Institute
80 Bloor St. West, Suite 1100, Toronto, ON M5S-2V1, Canada
416-929-6958

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Acupuncture and alternative medicine in Toronto from Pacific Wellness.
Acupuncture, shiatsu, RMT massage, naturopathy, reflexology and other alternative modalities for wellness, weight loss, fertility, pain control.