“There are no rules, only choices"

Client Questionnaire

Name *
Name
Date of Birth
Date of Birth
Best Phone Number to Reach You
Best Phone Number to Reach You
Please explain (medical/accupuncturist/herbalist/nutritionist/ psychotherapist)
Please explain all ailments and which physicians are dedicated to what aspect
Please list all medications/herbs prescribed by the above physicians.
Medical History
Please check all that apply
If yes please specify
Please list all
Please list any Chemotherapy and or Radiation treatments you have had and the dates.
(Cyst, Tumor, Cancer)
Current Lifestyle
Check all that apply
Current Diet
Check all that apply
Emotional Environment
Emotional Environment
I Am Happy
My Home Life Is Great
I Love My Job
My Current Mood/Emotional State is Great
I Experience Recurring Emotional Patterns
0 = No Pain / 10 = Unbearable Pain
Please be as detailed as possibleWh
List your top 3
i.e. dairy, red meat, chicken, fish, eggs
Please explain
Choose the one that most closely fits.
Please explain in detail.
Please explain in detail.
Please explain in detail.
Please be as detailed as possible.
Please explain in detail.
Commitment & Goals
Commitment & Goals
I Am Committed To Achieving My Goals
I Trust Myself and My Choices
I Trust This Process
I Believe In Myself