Date
Name
Address
Email
Phone:
Age & Date of Birth
Place of Birth
Height/Weight
Relationship Status
Children
Occupation
Average number of hours worked per week
Do you sleep well?
Do you wake up at night?
Constipation?
Blood Type (if known)
Ancestry
Are your periods regular?
Painful/symptomatic? Explain.
What medications/supplements do you take?
Are there any other healers, helpers, therapists or pets with which you are involved?
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes or have any other major addictions? Explain.
Any history of serious illness/injury? Explain.
Health of your mother?
Health of your father?
What is your main health concern?
Other concerns:
What was your diet like as a child?
What was your diet like one year ago?
What is your diet like now?
