Name
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First Name
Last Name
Prounouns:
Email Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Birth Date
MM
DD
YYYY
Birth Time
Hour
Minute
Second
AM
PM
Birth Location
Describe any current health issues you face (mentally, physically, spiritually, emotionally) Please be as specific as you can be.
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List past medical history (injuries, accidents, surgeries, etc) Please describe and include approximate dates.
Do you currently take any medications?
If so, what are they?
Do you currently find any regular or daily activities difficult or limited?
If so, please describe.
What are your goals in seeking out alternative care?
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Please list any other kind of healthcare professional you are seeing, or have seen recently?
How much time do you have for yourself to relax, and what activities aid in that relaxation?
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How is your sleep? How many hours, on average, do you get and is your sleep restful? If not, please explain.
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Would you consider yourself 'addicted' to anything currently? Please describe the relationship. Are you seeking to change this relationship at this time?
Take a minute to scan your whole body with your awareness. Please check all the boxes for which you experience pain, tension, discomfort, or blockage.
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Are there any of these you would like to elaborate on? You can include details, level of pain (1-10), etc
Rate your level of family stress
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None
Minimal
Moderate
Severe
Rate your level of work stress
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None
Minimal
Moderate
Severe
Rate your level of relationship stress
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None
Minimal
Moderate
Severe
Rate your level of financial stress
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None
Minimal
Moderate
Severe
Rate your level of health-related stress?
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None
Minimal
Moderate
Severe
Please feel free to elaborate on any of the scales above, or add your own area of stress that you'd like to bring forth at this time.
Overall, do you experience any of the following feelings to a degree to which you seek help or inquire about? Check all that apply.
Please feel free to elaborate on any of the above feelings, or add your own that exemplify your current experience affected Health.
DIGESTION: Which, if any, do you experience, or have experienced in the recent past?
RESPIRATORY: Which, if any, do you experience, or have experienced?
CARDIOVASCULAR: Which, if any, do you experience or have experienced?
URINARY: Which, if any, do you experience or have experienced?
NERVOUS: Which, if any, do you experience or have experienced?
MUSCULAR: Which, if any, do you experience or have experienced?
OTHER: Which, if any, do you experience or have experienced?
Any other additional comments appreciated!