Phone: Cell/Landline (circle one):_________________________________
Date of Birth:________________Age:_____________________________
How did you hear about my office and services?_____________________
Do you have any health/life concerns?_____________________________
Do these concerns affect your life?_____________
How? Circle what applies – Work Family Relationships Hobbies
Life enjoyment Relaxation Other:_____________________________
If you didn’t have these concerns how would your life be different?____________________________________________________________
PHYSICAL TRAUMA HISTORY- circle what applies
Forceps delivery Falls of any type Broken bones strains/sprains
Poor posture poor sleeping habits repetitive movements
Sports injuries heavy lifting/bending overweight auto accident
CHEMICAL STRESS – circle what applies
Prescription medication Over the counter drugs Marijuana
Alcohol Tobacco ecigarettes eat fast food
artificial sweeteners white flour/white sugar processed food
Exposed to environmental pollution Overweight Allergies
EMOTIONAL STRESS – circle what applies
Divorce – parents or spouse Death of a loved one Serious illnes –
self or loved one
Financial concerns Worry Work environment Relationships
Anger by you or at you Feel “not worthy” Put things off to the last
Which of the 3 types of stress has had the greatest impact on your well being and why?
PAST MEDICAL HISTORY
Please list any past medical history including – surgeries, procedures, medical diagnoses…________________________________________________________________________________________________________________________
Have you ever had any problems/diagnosis/treatment for any of the following? circle what applies
Skeletal System – Bone conditions…
Muscular System – Muscles, tendons, ligaments, joint pain, neck pain, back pain > upper, middle, lower, arms, legs, shoulder, feet, jaw
Respiratory System – Lungs, Bronchial tubes, Pulmonary problems, chest pain, difficulty breathing, other…
Digestive System – Stomach, intestines, pancreas, gall bladder, liver, heartburn, diarrhea/constipation, digestion problems, other…
Nervous System – Seizures, poor memory, lack of coordination, other
CardioVascular System – Heart, cardiac vessels, hypertension, blood
Urinary System – Kidney, bladder, infections, other
Reproductive System – Uterus, ovaries, fallopian tubes, cervix, prostate
LymphImmune System – frequent infections or colds
Integumentary System – skin disorders
Endocrine System – Pituitary, Pineal, Hypothalamus, Thyroid, Parathyroid, Thymus, Adrenals, Pancreas, Ovaries/Testes
Do you exercise? If so, what do you do and how often?
Do you meditate? If so, how often?
Do you do a spiritual practice?
Do you receive any other healing work regularly? If so, what kind and how often?
Do you get out in nature often?
What foods do you eat most often?
What diet do you follow? Vegan – Vegetarian – Non-vegetarian Fast Food, Other…
Are you willing to change? If not, you might consider seeing another practitioner.
What are your Goals/Expectations for seeking care at this office?
Do you understand that my practice isn’t about symptom care or pain relief but is about freeing your Life Force to activate optimal health and well being? Yes No