Holistic Health Questionnaire
Please complete this form before your first appointment with Liz Mirabile
What is your goal in coming to see me? *
Your answer
Any Allergies (pollens, molds, foods, perfumes, animals, chemicals)? *
Your answer
Do you suffer from asthma?
Have any skin conditions such as eczema, psoriasis, hives? If so, what kind of treatment have you sought out?
Your answer
Any serious hospitalizations/illnesses? *
Your answer
Any recurrent yeast infections/strep infections, other? Frequent antibiotic use?
Your answer
On average, what is your stress level? Anxiety? Depression? *
Your answer
Digestion issues (gas, constipation, diarrhea, bloating)? *
Your answer
Describe your diet: *
Your answer
How is your sleep? *
Your answer
PMS, hot flashes, menstrual pain, irregular periods, mood swings? *
Your answer
Headaches/migraines? Triggers? *
Your answer
Joint pain? *
What supplements/medications are you currently taking *
Your answer
Any therapies or healers with which you are involved? Other support? *
Your answer
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