Summit Health Questionnaire Please enable JavaScript in your browser to complete this form.Full Name *Email *Full AddressFull Address - Street, City, State, ZipPhone Number *Referred ByIf someone referred you please let us know whoHeightWeightAgeSexMaleFemaleMarital StatusMarriedSeparatedDivorcedSingleWidow or WidowerOccupationBlood Pressure (If Known)Cholesterol (If Known)Heart Rate (If Known)Pulse (If Known)Please list any other known lab valuesAre you currently under doctor care?If Yes, please give reasonPlease indicate any health diagnosis and medication for treatmentPlease include Diagnosis with MedicationApproximately how much are you currently spending per month on medication?Please list any vitamins & supplements you are currently taking and what it is forPlease list supplement and what it is taken forDo you currently take any non-prescription drugs?If yes, please list what you are currently taking and quantityOn a scale from 1-10 please rate your health123456789101 is very poor 10 is extremely goodPlease list at least 4 health goals or symptoms you would like to resolveIf you drink alcohol, how much do you drink?If you smoke, how much do you smoke?Please list any other habits that might effect your health Do you have any drug allergies? If yes please explainDo you have any other allergies? If so please explainDo you have any family history of health conditions? If so please list and explain.On a scale from 1-10 please rate your current exercise habits123456789101 is poor 10 is extremely goodWhat type of exercises do you currently do and how often?What sports do you play and how often?On a scale from 1-10 rate your overall stress level123456789101 is very poor 10 is extremely goodOn a scale from 1-10 rate your overall dietary habits123456789101 is very poor 10 is extremely goodHow often do you eat fast food?Describe in detail how often you eat fast food.How often do you drink coffee? How many (8oz.) cups per day/week/month etc.How often do you drink Tea?How many (8oz.) cups per day/week/month etc.How often do you drink water?How many (8oz.) cups per day/week/month etc.How often do you drink soda (regular - not diet)How many (8oz.) cups per day/week/month etc.How often do you drink diet soda (sugar-free)How many (8oz.) cups per day/week/month etc.How often do you drink milkHow many (8oz.) cups per day/week/month etc.How often do you drink other liquids (juices, shakes, etc)How many (8oz.) cups per day/week/month etc.On a scale from 1-10 rate your dairy consumption123456789101 is not very often 10 is very often On a scale from 1-10 rate your food portion sizes123456789101 is very small 10 is a large amountDo you eat breakfast? If yes, what time do you generally eat and explain what a normal breakfast would be for you.Do you eat lunch? If yes, what time do you generally eat and explain what a normal lunch would be for you.Do you eat dinner? If yes, what time do you generally eat and explain what a normal dinner would be for you.Describe the type of meals you eat and what you eat between mealsInclude snacks and detailed description of your eating habitsWhat time do you generally go to bed?How many hours of sleep do you get a night on average?On a scale from 1-10 rate your overall quality of sleep123456789101 is very low quality 10 extremely good nights sleepIf you have sleeping issues, please give as much detail on your biggest problems with sleep and how often you have the issuesDo you pray? If so how often?Do you meditate? If so how often?Do you get massages? If so how often?Do you get aromatherapy? If so how often?Do you do yoga? If so how often?Please list any other mental or spiritual lifestyle activities you do with a some detail about eachIf you do none of the above please give an explanation of things you would like to do more and also explain things from above you don't want to doPlease be descriptive on things you would or would not like to do more with mental or spiritual activitiesOn a scale from 1-10 rate your overall satisfaction with your emotional life123456789101 is not satisfied at all 10 extremely satisfiedIf you gave yourself a rating below 6, explain the reasons you are not satisfied with your emotional lifeOn a scale from 1-10 rate your overall satisfaction with your professional (work) life123456789101 is not satisfied at all 10 extremely satisfiedIf you gave yourself a rating below 6, explain the reasons you are not satisfied with your professional (work) lifePlease check how you would like to be contacted to obtain your resultsPhoneEmailPersonal visit (if local)If you chose phone, please let us know the best time(s) to callCommentSubmit
