Date Name Address Phone Number Email

These questions will give me a better understanding of any health issue you are facing. The best answer is the first one that comes to your mind. Don’t over think it! It is meant to be simple and informative…

State of Health 1st Concern or Reason for visit What type of breakfast do you normally or most often eat? Explain your typical diet How many hours of sleep each night? How many hours a week of stressful work? Approximate number of alcoholic beverages a week Approximate hours of down time to yourself Amount of exercise or activities per week, (includes chasing the kids around the yard) Your very favorite activity Your favorite foods How often do you get outside in a day or is most of your day spent working inside? What is your favorite source of indulgence? Do you experience joy and laughter on a regular basis? Name Experiences with Alternative or Integrated Therapies How would you describe your current motivation or explain your emotional level Are you currently taking medication, supplements or herbals? Please List and for what condition Do you have a spiritual practice?