Client Questionnaire

Name *
Name
Date of Birth
Date of Birth
Phone Number
Phone Number
Please explain (medical/acupuncturist/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.
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 possible.
List your top 3.
i.e. dairy, red meat, chicken, fish, eggs.
Choose the one that most closely describes you.
Please explain in detail.
Please explain in detail.Do you
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 voice
I trust this process
I believe in myself