Date
Name
Address
Email
Phone
Age and date of birth
Place of birth
Height & Weight
Relationship status
Children
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?
Other Concerns
What was your diet like as a child?
What was your diet like one year ago?
What is your diet like now?
What positive changes have you made since our last appointment?
What are your main concerns at this time?
Any changes in your weight?
How is your sleep?
Constipation/Diarrhea?
How is your mood?
Are you cooking more?
What foods do you crave?
Quintessential Myofascial Release and Wellness