Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
*
Marital Status
Children
Occupation
Do you enjoy your work?
Reason for Consultation / Treatment
How are you feeling today?
Are you receiving any other therapies? If so, what are they?
Physician's Name
First Name
Last Name
Physician's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician's Consent Required?
Yes
No
Do you suffer from medical conditions of:
Heart
Liver
Kidneys
Pancreas
Thyroid
Nervous System
Stomach
Bowels
Lungs
Back / Spine / Joints
Other
Please provide any details necessary to the above medical conditions.
Any current medications?
Past medications, with dates taken / prescribed?
Do you suffer from allergies related to:
Skin
Respiratory System
Food
Other
Please provide any details of your allergies, such as triggers / coping mechanisms / medications / etc.
Appetite
Good
Poor
Meals
Regular
Irregular
Digestion
Good
Heartburn / acid reflux
Bloating
Other
Please provide any details, if needed, regarding your digestive health.
Typical Daily Diet
Breakfast / Lunch / Mid-Afternoon / Evening / Coffee + Tea / Alcohol
Daily Bowel Movements
Good
Poor
Bowel Discomfort
Constipation
Diarrhoea
Pain
Alternating
Bloating
Other
Urinary System Concerns
Cystitis
Prostate
Discomfort
Other
Please provide any details, if needed, regarding your urinary health.
Respiratory System Concerns
Asthma
Sinus
Ears
Other
Please provide any details, if needed, regarding your respiratory health.
Lymphatic System Concerns
Swollen Glands
Sore Throats
Swollen Ankles
Frequent Colds
Other
Please provide any details, if needed, regarding your lymphatic health.
Circulatory System Concerns
Good
Poor
Cold / Warm
Varicose Veins
Hypertension
Hypotension
Other
Please provide any details, if needed, regarding your circulatory health.
Skin Concerns
Normal
Dry
Sensitive
Oily
Combination
Eczema
Psoriasis
Other
Please provide any details, if needed, regarding your skin health.
Musculo-Skeletal System Concerns
Injuries
Stiffness
Pain
Other
Please provide any details, if needed, regarding your muscular and/or skeletal health.
Menstrual Cycle
Regular
Irregular
Next Due Date
MM
DD
YYYY
Additional Reproductive System Concerns
PMT
Dysmenorrhoea
Amenorrhoea
Menopausal Difficulties
Hot Flashes
Other
Please provide any details, if needed, regarding your reproductive health.
Male Reproductive System Concerns
Prostate Issues
Impotence
Other
Please provide any details, if needed, regarding your reproductive health.
Nervous System Concerns
Headaches
Epilepsy
Depression / Anxiety
Sleep Pattern Issues
Other
Please provide any details, if needed, regarding your nervous system health.
Stress Level
1
2
3
4
5
6
7
8
9
10+
Please provide any details regarding common sources of stress in your life.
Energy Level
Good
Poor
Erratic
Fatigue
Other
Please provide any details regarding your energy levels.
Please describe any weekly exercise performed, if any.
What activities do you do for "time out" / personal relaxation / recreation?
Do you smoke?
Yes
No
Are you commonly around people that smoke?
Yes
No