Allmond Wellness 37

Please Complete this Pre-Screening Questionnaire

PLEASE NOTE: This message contains confidential information and is intended only for applicant and it’s intended recipient.
We do not and will not share any information contained in this questionnaire with any third parties.

Please review the “Ideal Allmond Wellness Client” Agreement BEFORE proceeding.

Ideal Client Agreement

Deanna wants to be sure that we are a good match so, please review the following “Ideal Client” criteria before proceeding with pre-screening questionnaire. An ideal Allmond Wellness client must meet ALL of these stipulations:

1. Must not have a history of psychotic symptoms.


2. Must not have a current history of suicidal or homicidal thoughts.


3. Should not have any active substance ABUSE issues ie. Alcohol, opiates, stimulants (cocaine, methamphetamines), marijuana.


4. Should not be taking any controlled substances such as opiates, benzodiazepines, or stimulants. These drugs are toxic to the brain and will impede Allmond Wellness healthy brain progress.


5. Should not be taking more than one or two psychiatric medications.


6. Should be motivated to treat mental health symptoms naturally.


7. Should be highly motivated to make recommended changes in the name of brain health and longevity (diet, exercise, supplements, removal of toxic exposures)
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First Name
Your First Name
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Last Name
Your Last Name
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Date of Birth
D.O.B
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Address
Street, City, State, Zip
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Email Address
Your E-mail Address
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Phone Number
(000) 000-0000
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How Did You Hear About Us?
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Services Seeking
Please select one.
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Current Mental Health Symptoms
Please list all that apply.
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Previous Mental Health Medication Trials and Responses
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Mental Health Diagnoses
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Family History of Medical Diagnoses
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Current Psychiatric Medications and Responses
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Family History of Mental Health Diagnoses
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Previous Mental Health Treatment (including therapy, hospitalization, and psychiatric care)
mm/dd/yyyy - Location
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Personal Medical Diagnoses (chronic pain, fibromyalgia, diabetes, thyroid disease, chronic infections, heart disease, cancer)
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Do you have any gastrointestinal symptoms on a regular basis? Please list: diarrhea, constipation, heartburn, nausea, gas, or bloating.
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Primary Care Physician Name - Medications Prescribed
Physician Name - Medication Name
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Surgical History
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Height and Weight (Also, have you experienced any recent weight loss or gain of 10 or more?)
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Current Supplements or Vitamins
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Have you EVER experienced suicidal or homicidal thoughts?
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Nicotine Usage (vaping, chewing tobacco, or cigarettes)
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Marijuana, CBD and THC Usage
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Have You EVER Experienced Psychotic Symptoms?
(heard voices or saw things that weren’t there or experienced delusional thoughts?)
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Alcohol Usage
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Caffeine Consumption
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Typical Diet (Vegan, Vegetarian, Flexitarian, Gluten Free, Dairy Free, Standard American)
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Level of Exercise/Activity Per Week
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What is your typical sleep/wake pattern? (Do experience nightmares, difficulty falling asleep, difficulty staying asleep, snoring?)
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What do you do to relax and how much time do you set aside each day to purposefully relax?
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Education History (high school, college, graduate school, trade school)
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Current Employment and Occupation
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Do you enjoy your job?
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Primary Supports and Household Information (are you married or single, do you have children? who lives in your household?)
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Any religious affiliations?
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Childhood History (Did you have a good childhood? Any childhood trauma (accidents, losses, abuse or legal issues?))
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Any traumatic events from your past that continue to impact your mental health today? Please briefly list here if you are comfortable doing so....
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Please describe a time in your life when you felt mentally and physically at your best. What was happening at this time that contributed to your well-being? Do you believe that you are able to get back to that state?
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What are your current mental health/brain health goals?
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What is the full name of your medical insurance provider and what type of plan is it (PPO, HMO, Medicare, Medicaid)?
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Best Method and Time for Consultation (Zoom, telephone)
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Best Payment Option
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IMPORTANT PRACTICE NOTES

Any recommendations shared during consultation should be discussed with your personal care provider.

Under no circumstances will Deanna prescribe controlled substances such as benzodiazepines, stimulants, or opiates.
These drugs are not conducive to good brain health and longevity.

*PLEASE INCLUDE COPY OF FRONT AND BACK OF INSURANCE CARD IF HAVING GENETIC TESTING ORDERED*