Health Questionnaire

For Consultation with Michelle Haley DHHP, HTMA Practitioner, BCST

I understand that Michelle Haley DHHP is not a licensed medical practitioner and that the services sought out by me with Michelle Haley DHHP are not licensed by the province of Alberta. I have freely chosen to use the services offered by Michelle Haley DHHP, and agree to be personally responsible for the consultation fees of Michelle Haley DHHP, in connection with the services provided to me, and that these services provided by Michelle Haley DHHP may not be covered by my health care insurance plans.

I the client, give my consent to Michelle Haley DHHP, to keep a file with my personal information, whether given orally, in writing or electronically. My typewritten signature below provides consent for Michelle Haley DHHP, to gather in a secure confidential file from now on, all information that I provide. Unless I instruct otherwise in writing, this consent will extend for seven years from the last information provided.

I the client, understand that the services and objective testing methods provided by Michelle Haley DHHP are not utilized nor intended for diagnostic purposes. I am aware that Michelle Haley DHHP, may not perform any medical act reserved for licensed professionals. These include (but are not limited to) diagnosing, prescribing, and discontinuing pharmaceutical medication. For these services, I may see a medical doctor.

I the client am not an employee of, nor associated with, any institution or government office that could gather any material or information, spoken or observed, for the purpose of entrapment or any action (legal, journalistic, or otherwise) against Michelle Haley DHHP.

I the client, agree that if at least 24 hours’ notice is not given for canceling or rescheduling an appointment, the full session fee is due and payable to Michelle Haley unless this appointment can be filled by another client.

Acknowledgment and Consent to Choose and Receive Services:
I have read and understand the above disclosure.

I understand the statements above and I'm ready to proceed with the Health Questionnaire (please type your initials in the space provided):

Date

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Place of Birth (for CoRe Analysis):

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

Phone

(###)

###

####

Google Meet will be the automatic way that you and I will connect for your consultation. Should this platform have issues, please let me know the best secondary way to contact you:

Please list your selection's contact ID, such as number to FaceTime, or best phone number to reach you:

I am

Who may I thank for referring you to my clinic

First Name

Last Name

Health History & Health Goals

What colour best reflects your natural hair colour: blonde, black, brown, grey, red:

What is your ethnic origin (necessary for TEI lab form): caucasian, hispanic, black/African American, Asian, other:

For Women: Are you pregnant?

Please list your health concerns to which you are seeking my support. What are your health goals?

Have you ever been diagnosed with a medical condition? If so, please list:

On a daily basis, how would you characterize your stress levels? What in your opinion is your biggest source of stress?

List all medications that you are currently taking from your Medical Doctor as well as over the counter medications:

Please describe your daily elimination habits (bowel movements) and most importantly, please let me know if you experience diarrhea on a regular basis and if so, how often?

List all supplements, including greens concentrates that you are currently taking:

Do you maintain any type of dietary pattern (ie. vegetarian, vegan, keto, grain-free, gluten-free, etc)? If so, please list which one. For how long?

What type of water do you drink on a daily basis? What is the source? (i.e., tap, filtered tap, spring water, distilled water, filtered water - please list source)

Do you have a water softener in your home? If so, are you drinking this directly or is there another stage of filtering? If so, what style of filtration?

For women: Please list your birth control history including the use of birth control pill, IUD (Copper or hormonal) Do you live in a home with copper water pipes?

For women: how many pregnancies have you had?

For men: Do you know if your mother was on birth control pill or copper IUD prior to your pregnancy and birth?

Have you ever had or do you still have amalgam (silver) fillings?

Root canals and dental implants: Do you currently have one or more root canals or dental implants in your mouth? Please provide details and make note if you've ever had a dental abscess.

Dental Appliances: Please list any dental appliances that you currently have in your mouth or use regularly: (bonded metal retainers, plastic retainers, etc.)

For understanding how your nervous system handles conflicts and trauma, what is your dominant handedness?

Please list your Blood Type if you know it:

Please list any major surgeries and other physical/emotional traumas and approximate dates:

Were you born vaginally or via C-Section? Please feel free to make a note of other information you have about your birth or your mother's pregnancy (i.e. her health at that time or traumas she may have experienced while she was pregnant with you).

Daily Habits

How many 8 oz or 225 ml glasses of pure water do you drink on a daily basis?

Please list your daily selection of foods for all meals:

Describe your daily sleeping habits, hours of sleep per night and if you feel rested in the morning. Provide any other information regarding your sleeping habits:

Exercise

What do you do for Exercise?

Body weight: What is your approximate weight. Are you at your desired body weight?

Alcohol Consumption

Caffeine Consumption

Do you smoke?

Do you use any recreational drugs?

Include any other comments regarding your medical history or health goals that you would like to share:

In five years, what goals or accomplishments would you like to have met?

Please type your full name as replacement for your handwritten signature:

Thank you for taking the time to fill this form out. This information that you've provided will be upheld with the utmost confidentiality and is helpful for me to support you on your individualized healing journey... Michelle Haley DHHP.