– none – Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
– select – United States
Emergency Contact – Name *
Emergency Contact – Phone *
How did you find out about the Prama Wellness Center?
Do you engage in regular physical exercise?
Type of Physical Exercise
Do you suffer from any kind of sleeping problems?
If yes, what kind of sleeping problems do you have?
Type of Sleeping Problems
Which of the following are part of your dietary habits? (Check all that apply)
How often do you snack between meals?
– select – Never Rarely Once a day Twice a day Many times a day
Before eating a meal, you are usually
Hunger before meals *
– select – Not hungry Sometimes hungry Always hungry
How much water do you drink in a day, not including water taken near or during meals? (1 Liter = 4 glasses)
Drinking Water *
– select – Less than 1 liter 1 to 2 liters 2 to 3 liters 3 to 4 liters 4 to 5 liters More than 5 liters
– select – Never Rarely Sometimes Regularly
If you fast regularly, how many times per month do you fast and when was the last time you fasted?
What types of fasting have you experienced? (Check all that apply)
How often do you drink alcohol?
Alcohol Consumption *
– select – Never to occasionally Occasionally (1-5 alcoholic drinks per week) Frequently (2-3 alcoholic drinks per week) More Frequently
How often do you smoke cigarettes?
Smoking Tobacco *
– select – Never to occasionally 1 or 2 cigarettes a day Less than a pack a day More than a pack a day
How often do you take medicines?
– select – Rarely Occasionally Often Daily
Please provide the names of the medicines that you are currently taking?
Have you had any operations?
If yes, what kinds of operations have you had?
How often do you have bowel movements (stool)?
Bowel Movements *
– select – 1x a day 2x a day 3x a day Frequent constipation Frequent diarrhea
Do you have gas problems?
Gas Problems *
– select – None Sometimes Frequent
Do you have any allergies?
If yes, please list them below:
Do you frequently have body pain?
If yes, please describe the types of body pain that you are experiencing?
Please list any stress or emotional issues that you feel may affect your everyday activity and physical health.
Please list any psychoactive drugs you are currently taking.
Please describe any other health problem that you have?
Please provide any other relevant information.
Disclaimer: This health form is not used to diagnose or treat any disease. When making changes to your diet or lifestyle, you are advised to consult with your doctor.