Welcome! Please take a few moments to answer the following questions so that we can have a well-rounded
picture of your overall health, and therefore serve you to our greatest ability.
Name ___________________________________________________ Class _______________________
Address_______________________________________ City/State/Zip___________________________
Home Phone____________________ Work/Cell Phone___________________ Birth date____________
Occupation __________________________ e-mail:__________________________________________
In Case of Emergency Contact: name & phone______________________________________________
Reason for class or session: ______________________________________________________________
_____________________________________________________________________________________
Do you currently, or have you any history of cancer, stroke, cardiovascular disease, or diabetes? _______
_____________________________________________________________________________________
Significant family history (cancer, cardiovascular disease, diabetes, stroke, etc.) ____________________
_____________________________________________________________________________________
Please mark areas where your body has felt or is currently feeling a lack of ease or discomfort.
__head __face __neck __chest __shoulders __arms
__sternum __rib cage __abdomen __elbows __wrists __fingers
__upper back __mid back __low back __buttocks __tail bone __legs
__feet __toes __knees __breathing __sacrum __clavicle
__heart __lungs __ankles __eyes __hips __hands
Please mark areas where you have experienced problems:
__thyroid __nervousness __sweating __headaches __allergies __ digestion
__circulation __depression __memory __vision __prostate __circulation
__fatigue __anxiety/panic __speech __eyes __urinary __appetite
__constipation __blood pressure __breathing __sleep __weight __diarrhea
__blood clots __tasting __stress __hearing __asthma __incontinence
__smelling __spine __gas __tumors __organs __dizziness
__fainting __varicose veins __sciatica __weakness __sinuses __other
IMMUNE SYSTEM
In general, how do you tend to heal? ___ slowly ___ average ___ quickly
How many colds/flues do you experience each year? __________________________________________
When do you have a cold/flu, how many days do they last? _____________________________________
How do you take care of yourself when you don’t feel well? ____________________________________
Are you currently experiencing, or have you in the past experienced any immune system disorders? (e.g. Epstein-Barre,
Thyroid issues, Lupus, HIV, etc) ______________________________________________
NERVOUS SYSTEM
Are you currently, or have you in the past had problems with any of the following?
__dizziness __radiating pain __panic attacks/ __walking
__tingling __muscle spasms anxiety __falling down
__tremors __numbness __muscle weakness __other
__coordination __balance __ nervousness
REPRODUCTIVE SYSTEM
Women:
Are you pregnant? _____________ If so, due date________________
Where do you plan to give birth? ___ home ___birth center ___ hospital ___ other
How many children do you have? _______ # of pregnancies ______ Are you on birth control? ________
Do you experience any menstrual problems/irregularities? ______________________________________
Any breast changes/concerns? ___________________________________________________________
Are you going through, or have you gone through menopause? ______ Any concerns? ______________
Have you had a hysterectomy? _______ If so, when? _________ Hormone replacement therapy? ______
Do you have any other reproductive concerns? _______________________________________________
When was your last physical exam? _______________________________________________________
Men:
Are you noticing any changes in your reproductive system that are causing you concern? _____________
Any urinary problems/changes/difficulty? __________________________________________________
When was your last physical exam? _______________________________________________________
ACCIDENTS/TRAUMA
List any accidents, falls, athletic injuries, and other physical traumas: _____________________________
_____________________________________________________________________________________
Have you ever been admitted into a hospital? _______ If so, why? _______________________________
_____________________________________________________________________________________
Do you know anything about your birth process? ___yes ___no
Please answer the following according to your comfort level:
Have you experienced any emotional trauma from which you have not yet recovered? ___yes ___no
Have you ever experienced any form of abuse? ___yes ___no
LIFESTYLE
What do you do to take time for yourself, that brings you joy and/or feeds your soul? ________________
_____________________________________________________________________________________
Do you participate in yoga, meditation, or any other spiritual practice? ___yes ___no If so, please describe _____________________________________________________________________________
Do you participate in any exercise or sports?_________________________________________________
How would you describe yourself in the following areas?
Emotional health ________________________________________________________________
Physical health _________________________________________________________________
Mental health __________________________________________________________________
Overall quality of life ____________________________________________________________
Mark all health care treatments you have utilized:
__chiropractic __homeopathy __herbs
__massage __acupuncture __colonics
__other forms of bodywork __water therapy __other__________________________
When you are not feeling well, your first choice of health care is: ___holistic ___medical ___other
List all medications (prescription and over the counter) you are currently taking: ____________________
_____________________________________________________________________________________
Mark all of the following that you use regularly:
__ alcohol __recreational drugs __caffeine
__tobacco __soft drinks __aspartame (nutrisweet)
Patient Signature:___________________________________________Date:_____________________
Permission to work with a minor:
Parent/Gaurdian consent and signature:_____________________________________________________
