So I can support you best on your health journey please take time to reflect on the following questions and indicate the following: Is your concern affecting you at the moment? If so please describe the feeling and how often you feel this way. If your/some of your concerns have been in the past please describe when, how often and for how long they have been affecting you. Name * First Name Last Name Date of Birth Place of Birth & Time (if you have it) Email * Reason/s for consultation? * Phone * What is your primary goal or concern physically, emotionally, mentally? * Do you have any injuries, pain or discomfort (including digestive complaints) * What were you doing when it started? What other things were happening in your life at that time? * Do you find your symptoms get worse when you are in or around certain environments or people? * When did you last feel well? * Do you have any allergies or food sensitivities/intolerance? * Please list what you would normally eat for breakfast, lunch & dinner along with times of meals. Include snacks and drinks. * Do you have any food cravings? * Do you smoke or drink alcohol? If so please explain * Do you use any recreational drugs? * Do you have a physical exercise routine? * Do you get adequate sleep? * What emotions do you regularly feel throughout the day? * What best describes you from the following? The Peacemaker (always concerned about pleasing others, loves to be of service, seeks harmony & togetherness, tends to worry/have self-doubt. The Alchemsist (likes perfect order, finer details, high standards, respect & morals, refined tastes, finds it challenging to let go of grief.) The Philosopher (always seeking knowledge & understanding, articulate & clever, likes solitude, at times can be challenged with fear or inadequacy.) The Pioneer (seeks challenge, adventure and pushes to the limit, assertive & confident, at times can be challenged with impatience/frustration & anger.) The Wizard (charismatic, enthusiastic & optimistic, spontaneous, sensual and delights in intimacy, extravagant, may be challenged with anxiety/insomnia) What helps you relax/be present? * What is your profession? * Do you enjoy your work? * What would you change about your life if you could? * Thank you!
