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2. If not already included in answer to #1 above, please describe any troubles you have with digestion (such as: loose stools, bloating, cramping, acid reflux, etc.).
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6. Past medical history (previous injuries, accidents, surgeries, etc. – with approximate dates).
5. If not already included in answer to #1 above, please describe any troubles you have with mental health (such as: anxiety, depression, learning disabilities, etc.)
9. What daily activities are you finding difficult or are limited because of your above conditions?
12. How much time do you have for yourself to relax and what do you do to relax, i.e. hobbies, meditation, etc.?
14. How many hours a night do you sleep? Is your sleep restful?
Health & Well Being Intake
4. If not already included in answer to #1 above, please describe any troubles you have with your respiratory system (such as: breathing, coughs, sinuses, allergies, etc.).
1. Describe any problem(s) related to your current health. Please include dates when each problem began.
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13. Do you exercise? And if so, what kind and how often?
3. If not already included in answer to #1 above, please describe any troubles you have with your muscles and joints.
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8. Are you allergic to any medications, foods or herbs?
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
10. Please list any medical tests you have had in the past year.
11. On a scale of 1-10, how high is your overall stress? Describe the source(s) of your stress: financial, relationships, job, health, etc.
7. List the medications (including over the counter) you are presently taking as well as any supplements you take daily.
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