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Client Information
Your Name
Birthday
Age
Height
Weight
Desired Weight Goal (If Applicable)
When's the last time you remember feeling really great? Finish this sentence for me: "I haven't felt great since…”
What are your primary concerns? These concerns can be physical, emotional, and spiritual.
Symptoms
Describe your symptoms and their location
Describe your symptoms on a good day
Typical Day
Worst Day
What makes it better or worse?
Have you seen a Naturopathic Doctor or Holistic Nutritionist for this symptom, if so what was the treatment and did it work?
What was going on in your life when the symptoms began?
Have you had Intolerance Testing? If so, please list allergens and intolerances
How much water do you drink daily?
Do you have Amalgam fillings? If so, how many? How long have you had them?
Have you received vaccinations? How Many? How Long Ago?
How many antibiotics have you used in the last year?
Last 5 years?
Lifetime?
List major surgeries and years it was performed
Any missing body parts or organs?
Any major past trauma to the body?
Any major shift in life circumstances within the last 5 years?
List of current medications
List of supplements if taking any
Happiness
Waking energy level
Evening Energy Level
Personal happiness level
Work
Family & relationships
Sleep
Total hours of sleep?
Total hours of uninterrupted sleep?
If you have disturbed sleep, what is the time of the disruption?
Do you dream?
Yes
No
Do you remember your dreams?
Yes
No
How long does it take to fall asleep?
Do you wake refreshed?
Yes
No
Digestion
What is your average number of bowel movements per day?
Do you have any days without a BM each week?
Yes
No
Do you have a BM within 2 hours of waking up?
Yes
No
Are your BMs complete?
Yes
No
Well formed?
Yes
No
Any blood?
Yes
No
Any mucus?
Yes
No
*MARK ALL THAT APPLY
Dark circles under the eyes
Acne
Eczema
History of asthma/sinusitis
Sore throat/stiff neck
History of hernias
History of acid reflux
History of migraines
History of ear itching/infections
Fatigue 2+ hours after eating
Itchy eyes
Nosebleeds
History of irritable or inflammatory bowel
Myofascial / Neurological
*MARK ALL THAT APPLY
Back pain
Shoulder pain
Neck pain
Sciatica
Carpal tunnel syndrome
TMJ syndrome
Numbness/tingling
Seizures
Muscle pain that moves from place to place
Male Reproductive
*MARK ALL THAT APPLY
Diminished urinary stream
Difficulty achieving erection
Difficulty maintaining erection
Are you on Hormones or hormone replacement therapy?
Yes
No
Female Reproductive
Menstrual cycle is:
Regular (4-6 days)
Long
Short
Menstrual flow is:
Regular
Heavy
Light
Are you on Hormones or hormone replacement therapy?
Yes
No
Acidity & Nutrient Deficiencies
*MARK ALL THAT APPLY
Red eyes
Sensitive skin
Hyperthyroidism
Hypothyroidism
Brittle nails/hair
Multiple broken bones
Clear urine
Arthritis
Easy bruising
Slow reflexes/recall
Cavities
High blood pressure
Low blood pressure
Heart palpitations
Kidney stones
High cholesterol
Digestive
*MARK ALL THAT APPLY
Constipation
Diarrhea
Alternating diarrhea & constipation
Nausea
Vomiting
Easy dizziness
Acid reflux
Hemorrhoids
Hernias
Flatulence
Rectal bleeding
Rectal itching
History of ulcers
Mucus in stools
Undigested food in stools
Clay colored stools
Emotion
Check all that apply
Fire: Unworthy/resistant to change/accepting of defeat
Earth: Busy as escape/excessive concentration/mental chatter/easily overwhelmed
Gold: Grieving/keeping it inside/can’t let go
Water: Lack of trust/afraid/worried/anxious
Wood: Angry/indecisive/frustrated/impatient/complaining/timid
Accessory Fire: Alone/isolated/neglected/guilt/excessive thought/second guessing self
Please leave this field empty.
Your email
Download the PDF If you would like to fill it out and email back to me.
