“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
If you are a male, please check N/A
Please list all
Please list any Chemotherapy and or Radiation treatments you have had and the dates. Or other treatments not mentioned.
(Cyst, Tumor, Cancer)
Current Lifestyle *
Check all that apply
Current Diet
Check all that apply
0 = No Pain / 10 = Unbearable Pain
If yes, please describe a typical breakfast.
Please be as detailed as possible.
List your top 3 go to treat foods for emotional eating and or snacking.
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.
Emotional Environment *
Please check all that apply.
Please explain in detail.
Please be as detailed as possible.
Please explain in detail.
Commitment & Goals *
Check All That Apply