ABIBA WELLNESS PRE-CONSULTATION FORM.

Please completely fill out the pre-consultation Form so that I will be able to address your health care inquiries.  After you have completed the form click on the submit button so your form can be forwarded to me at least 5 days before your actual consultation.  This form is mandatory for all consultations.

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  ABIBA WELL-BEING PRE-CONSULTATION FORM (All Information given is confidential ) Name:                                           Address:                                       State:     Zip:                       Current Phone:              e-mail address: Age:                         Female:             Male: PLEASE ANSWER QUESTIONS USING KEY:  A= USUALLY     B=SOMETIMES   C=NEVER 1. Do you feel well & energetic  2. Do you get all the sleep you need- 3. Do you exercise for at least 20-30   minutes three times a week? 4. Do you smoke? 5. Do you use potentially dangerous drugs? . Do you drink more than 2 drinks a day? 7. Do you keep your salt and sugar intake down? 8. Do you eat poultry and fish rathr than red meat? 9. Do you drink 6 to 8 glasses of water a day? 10. Do you skip meals? 11.Do you eat only when you're hungrey? 12. Do you avoid junk and processed food? 13. Do you refrain from fad diets? 14. Do you minimize your caffeine intake? 15. Does your spiritual life sustain you? 16. Do you feel that your life is out of control? 17. Do you find it difficult to relax _________________________________________________________________ KEY:  A=YES      B= NO   Have you ever had or now have any of the following: Asthma      Diabetes      Heart Problems       Dizziness Chest Pain/Angina       Extra Heart Beat      Black Outs      Rheumatic Fever       Cancer     Allergies to Medication      Allergies Food       Allergies to Bites/Stings     High Blood Pressure      Cysts or Lumps Sexually Transmitted Disease(s)         Hepatitis               Eye Problems         Skin Problems      Abdominal Problems        Neurological Problems          Ear-Nose-Throat Problems Eating Disorders       Orthopedic Problems        Are You Pregnant        Mononucleosis Yeast Infection         Hearing Loss Has any member of your family died from or now have any of the following? Sudden Death         Heart Disease       Diabetes     High Blood Pressure      Seizure Disorder       Sickle Cell Trait/Disease      If you answered Yes to any of the above please explain:             Have you had any other medical conditions not listed?  If Yes Please Explain