Health Consultation - Introduction Form
Take a moment to thank yourself for embarking on this journey and enhancing your health and wellbeing. Carve out a quiet ten to fifteen minutes to thoughtfully reflect on your wants and needs while responding to the questions below. Instead of solely focusing on one parameter of health (i.e. the physical body), the prompts are meant to glean aspects of the bigger picture. Your answers will help me get to know you and allow us both to gain clarity around how to best serve you during our time together.

Please think of me as a guide - here to support you, helping you to develop a keener sense of self-awareness and alignment of body, mind, and emotion. Ultimately you are the driver and director of your life. I am looking forward to working together and thank you for allowing me to be a part of this process as you continue to grow.
Name *
First and last name
Email *
Cell Phone Number *
Date of Birth in month, day, year format __/__/____ *
Place of Birth *
Relationship Status *
Number of Children *
Occupation *
Hours of work per week *
Hours of sleep per night (on average) *
Do you experience any trouble falling asleep, staying asleep, or waking up? *
Any serious illnesses/hospitalizations/injuries? *
Family history - How is/was the health of your mother, father, and siblings? *
Do any of the following illnesses run in the family? *
Required
Is there anything else in regard to family that you think to be relevant to our conversations - whether it be chronic disease, mental illness, parent divorce, or other significant events? *
How do you feel about the areas of social support in your life? (This can be fulfilled through family, friends, community, etc.) *
I feel as if I have no support at all.
I have as much social support and help as I need.
Food: Look back to the past few days. Choose one day that may represent your "normal" diet and summarize what you had for breakfast, lunch, dinner, and snacks. *
Any allergies, food sensitivities, or dietary restrictions? *
Do you take any supplements or medications? Please list the reason, dosage, and frequency. *
Physical Activity: If you are physically active, look back to the past few weeks. Choose one week that may represent your "normal" frequency and intensity of physical activity and describe those activities and the duration for each day practiced. (e.g. Monday - vinyasa yoga one hour class, Wednesday - walk 2 miles...etc.) If you do not engage in regular physical activity, simply enter "N/A" in this field. *
How many hours per week would you like to dedicate to physical activity and/or mindfulness techniques? Do you know which timeframes will work best with your schedule? Do you foresee any challenges or obstacles that may stand in the way? *
What are your favorite hobbies or leisurely activities? How do you like to spend your free time? *
Are there any healing modalities that you have found to be helpful - such as therapy, meditation, Reiki, yoga, etc.? *
Do you identify with any spiritual/religious affiliation?
Do you consider yourself to hold any major addictions? *
Required
How satisfied are you with your physical state - how you feel in your body, energy levels, and overall health *
Not satisfied at all
Very satisfied
How satisfied are you with your mental/emotional state - stress levels, peace of mind *
Not satisfied at all
Very satisfied
What are your main health concerns? *
What is/are the primary reason(s) for this consultation? *
Name one to three intentions that you would like to set in either the short-term or long-term. They can be big or small. (For some, it might be helpful to think of these as goals or objectives.) *
...
Is there anything else you would like to share? *
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