Whole body background information on physical. dietary, exercise, rest and relational capabilities of individual suffering from a chronic condition.

1. Randolph Coaching and Consulting LLC
Client Intake Questionnaire
Name:
Birth date: / / Gender: Marital Status:
Month and Year of First Symptoms: /
Favorite Activities Then:
Symptoms (list all you can recall, one as most painful or noticeable and five as least):
1)
2)
3)
4)
5)
Stress Factors Then (list all you can recall, one as most stressful, three as least, such
as illness of other, death in family, job loss, accident, etc.):
1)
2)
3)
Drink alcohol: Y or N No of drinks then per week:
Smoke/chew tobacco: Y or N No of times then per week:
Exercise Frequency Then: X per week: _____Av. Time per workout: ___
Type of workout: _________________ Location: ___________
Diet Then: X per week of fruits: _____ X per week of fish/chicken: ____
X per week of vegetables:___ X per week of red meat: ______
Average sleep hours per night then: ______
Date of First Medical Appointment: / /
Name of Physician/Healer:
Town/City Location of Physician:

2. Physician Recommended by Whom:
Tests Administered (bloodwork, CAT Scan, Western Blot, etc. & where):
Physician’s Assessment of Condition (name(s) of illnesses), if applicable):
Physician’s Recommended Actions for You:
List of All Medication(s) Physician Prescribed & Months You Remained on
Medication(s): (please write in following medication: ex) Aricept (10mns))
1) 4)
2) 5)
3) 6)
Effects of Consumed Medications on Your Symptoms: (what improved/what did
not)
Describe how you were feeling/functioning three months after this visit:
What new symptoms (if any) were you aware of three months after this visit:
What next step did you wish to take:
What was your actual next step and why:
Date of Second Medical Appointment: / / (if applicable)
Name of Physician/Healer:
Town/City Location of Physician:
Physician Recommended by:
Tests Administered (bloodwork, CAT Scan, Western Blot, etc. & where):

3. Physician’s Assessment of Condition (name(s) of illness9es), if applicable):
Physician’s Recommended Actions for You:
List of All Medication(s) Physician Prescribed & Months You Remained on
Medication(s): (please write in following medication: ex) Aricept (10mns))
1) 4)
2) 5)
3) 6)
Effects of Consumed Medications on Your Symptoms: (what improved/what did
not)
Describe how you were feeling/functioning three months after this visit:
What new symptoms (if any) were you aware of three months after this visit:
What next step did you wish to take:
What was your actual next step and why:
Date of Third Medical Appointment: / / (if applicable)
Name of Physician/Healer:
Town/City Location of Physician:
Physician Recommended by:
Tests Administered (bloodwork, CAT Scan, Western Blot, etc. & where):
Physician’s Assessment of Condition (name(s) of illness9es), if applicable):
Physician’s Recommended Actions for You:

4. List of All Medication(s) Physician Prescribed & Months You Remained on
Medication(s): (please write in following medication: ex) Aricept (10mns))
1) 4)
2) 5)
3) 6)
Effects of Consumed Medications on Your Symptoms: (what improved/what did
not)
Describe how you were feeling/functioning three months after this visit:
What new symptoms (if any) were you aware of three months after this visit:
What next step did you wish to take:
What was your actual next step and why:
Date of Fourth Medical Appointment: / / (if applicable)
Name of Physician/Healer:
Town/City Location of Physician:
Physician Recommended by:
Tests Administered (bloodwork, CAT Scan, Western Blot, etc. & where):
Physician’s Assessment of Condition (name(s) of illness9es), if applicable):
Physician’s Recommended Actions for You:
List of All Medication(s) Physician Prescribed & Months You Remained on
Medication(s): (please write in following medication: ex) Aricept (10mns))
1) 4)

5. 2) 5)
3) 6)
Effects of Consumed Medications on Your Symptoms: (what improved/what did
not)
Describe how you were feeling/functioning three months after this visit:
What new symptoms (if any) were you aware of three months after this visit:
What next step did you wish to take:
What was your actual next step and why:
Date of Fifth Medical Appointment: / / (if applicable)
Name of Physician/Healer:
Town/City Location of Physician:
Physician Recommended by:
Tests Administered (bloodwork, CAT Scan, Western Blot, etc. & where):
Physician’s Assessment of Condition (name(s) of illness9es), if applicable):
Physician’s Recommended Actions for You:
List of All Medication(s) Physician Prescribed & Months You Remained on
Medication(s): (please write in following medication: ex) Aricept (10mns))
1) 4)
2) 5)
3) 6)
Effects of Consumed Medications on Your Symptoms: (what improved/what did
not)

6. Describe how you were feeling/functioning three months after this visit:
What new symptoms (if any) were you aware of three months after this visit:
What next step did you wish to take:
What was your actual next step and why:
Your Current Condition (describe briefly):
What favorite activities can you no longer enjoy?
Current Symptoms (list all you that apply, one as most painful or noticeable & five as
least): 1)
2)
3)
4)
5)
Stress Factors Now (list all that now apply, one as most stressful, three as least, such
as your illness, other’s illness, family loss, job loss, accident, etc.):
1)
2)
3)
Drink alcohol: Y or N No of drinks now per week:
Smoke/chew tobacco: Y or N No of times now per week:
Frequency of Exercise Now:
X per week: _____ Time per workout: ________
Type of workout: _________________ Location: ___________

7. Diet Now:
X per week of fruits: _____ X per week of fish/chicken: ____
X per week of vegetables:___ X per week of red meat: ______
Average sleep hours per night now: ______
rr(6/17/09)