Medical History

Family Medical History (General Health)

Mother's side

Father's side

Siblings

If above deceased cause of death:

Childhood Health (Physical)

(Emotional)

Location of upbringing:

Current Emotional Health:

Current Predominant Emotion:

Current Quality of Life:

Current Relationship/Quality:

Is there much stress in your life?

What?

Hobbies and recreational habits:

Favorite time of year?

Worse time of year?

Do you have a regular exercise program?

Please describe:

Travel abroad within the past year?

Where?

Do you feel like you have a good appetite?

Good eating habits?

Please describe your average daily diet:

Morning

Afternoon

Night

Portion of Raw Food

To Cooked Food

Do you get cravings?

What/When?

Preferred Tastes:

Sour

Bitter

Sweet

Spicy

Salty

How many packs of cigarettes do you smoke a day?

How much coffee, tea or cola do you drink per week?

How much alcohol do you drink per week?

Please describe any recreational drug use (this info is strictly confidential):

Have you ever abstained or "quit" anything?

Do you have any nervous habits?

What factors in your life seem destructive to your daily health?

Are there any other problems, conditions, or observations that you would like to discuss?

What are your goals for health and life?

I recognize that the major factor in my health is myself, that one can do the healing for me, and that my participation in my own care is key. That without following the recommendations, taking herbs, doing the practices, shifting the lifestyle, etc little can be expected and no promise of result is offered.

Please Also Complete The General Intake Form

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