Health Form
Full Name: *
Address: *
Telephone number (cell):
Email: *
Reason for consultation: *
How did you hear about Re:source? *
Profession: *
--> Please list any health concerns: *
--> Please list all medication (including dose, frequency, and time of intake): *
Do you experience any side effects? Please list clearly: *
Are you taking any supplements, vitamins, herbs etc.? *
--> Are you currently seeing any other health care professionals? *
--> Please list any injuries – past or present, and cause: *
Please list any areas of pain, tension or discomfort in the body *
Please list sources of exercise, sport, or physical activity *
Please list sources of leisure, including hobbies and interests *
--> Diet
How would you describe your appetite? *
How many meals per day? *
How many snacks per day? *
How many tea/coffee per day? *
How many sweet/salty per day? *
How many Meat/fish/eggs per week? *
How many fruits per week? *
How many vegetables per week? *
How many sweets per week? *
Please comment on digestion
constipation, bloating, excess, etc.
Do you drink alcohol? *
Do you smoke tobacco? *
--> Sleep
How would you describe the quality of your sleep? *
Quality of rest: do you wake up rested, or still tired? *
Do you wake up during the night? *
How many hours do you sleep at night? *
Do you take naps? *
Please comment on dreams: *
--> Women
Comment on period/menopause:
Symptoms:
Cramping:
Mood:
Appetite:
Sleep:
--> Please describe the conditions associated with the following:
(if there is nothing noteworthy, leave space blank)
Sinuses
Eyes
Ears
Nose
Throat
Heart
Lungs
Breathing
Headaches:
Stomach
Liver
Skin
Hair
Nails
--> Is there anything you feel is important that has not been covered?
Re:source is not responsible for any pain or injury caused by the practice. All students are advised to work within their range of ease, and within their own limitations.
Please note that the cancellation policy ensures 24 hours warning prior to change, or cancellation of an appointment. Any cancellation effected within the 24 hrs prior the session will be charged at full fee.Thank you for helping us serve you best.
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