Constitutional Health Intake

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Thank you for taking the time to fill out this form. Please feel free to put question marks next to any sections that you have questions about, and please feel obliged to answer only those you are comfortable answering. During
the consultation we will go over this form together. All information is kept confidential.

This questionnaire asks you to assess how you have been feeling over the last 4 months. This information will help keep track of how your physical, emotional and mental states change as you adjust your eating habits, lifestyle choices, priorities, supplement program, exercise, stress management and personal growth.

Agreement*:

Please type your name as electronic signature; *Only a physician can diagnose, treat, and prescribe for illness or disease. I neither diagnoses nor treats disease. Nor do I prescribe remedies or cures. Products have not been evaluated by the FDA. These products are derived from ancestral, spiritual and/or historical practice.

Name *

Date and Time Birth *

YYYY

Time

Place of Birth

Occupation?

Passions?

How is your spirit today?

Please describe your symptoms and concerns *

How long have these issues been a concern? *

Please list medications; name, dosage, and frequency

Please describe any events or details that may be relevant to your condition

Have you received any diagnosis, treatment, or advice from an appropriate practitioner? What were their findings? *

Do you find relief with any of the following;

Exertion

Heat

Cold

Rest

Pressure

Other:

Clear selection

When, how, and why?

Please list relevant health history and any major procedures or diseases; *

Please list allergies to foods, drugs, environmental substances; *

Food Diary

Please create a food diary with approximate times and amounts; I.e. breakfast: 2 eggs, potato and a donut around 9 am lunch: dinner: snacks:

Breakfast; *

Lunch;

Dinner;

Snacks;

Plain water;

Please include volumes and times

Coffee;

Tea;

Smoothies;

Sodas;

Juices;

Please describe your urination and how often;

Please describe your bowel movements and how often;

Please describe your exercise routine:

What are your health and wellness practices? When?

Which types of therapies have you explored for your current concern(s)?

herbal medicine

acupuncture

energy work

chiropractic

nutritional/diet modification

pharmaceutical prescriptions

psychotherapy

physical therapy

Other:

Are you still using these therapies? Please explain...

Do you know your current blood pressure? What was the date taken?

What level of stress are you experiencing regularly lately?

little to no stress

paralyzing stress

Clear selection

Please describe the main contributors to stress:

How is your digestion? Please describe; *

How is the quality your sleep? How many hours do get a night on average? *

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