Describe the problem(s) for which you seek help. Please include dates when each problem occurred:

Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates:

List the medications (including over the counter) you are presently taking:

What daily activities are you finding difficult or are limited because of your above complaints:

Have you ever had this problem before, and if so when?

What are your goals from receiving therapy?

Please list any other kind of healthcare professional you are seeing for this/these problem(s):

Please list any medical tests you have had within the past year:

My family stress is:

My relationship stress is:

My work stress is:

My financial stress is:

My health stress is:

Please describe any other stress and it's severity 

How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc ?

Do you exercise? And if so, what kind and how often?

How many hours a night do you sleep? 

Is your sleep restful? If not, please explain: 

Please list areas of pain and describe the level of discomfort on a scale of 1 to 10.

1. Slight awareness of discomfort.

2-3. Awareness of discomfort as an aggravation.

4-6. Pain is strong but you are still functional.

7-9. Pain is so strong you are unable to function normally.

10. You feel like you need to go to the emergency room.

What are your top priorities in life?

Describe your hopes, dreams or aspirations?

What would your daily life be like if you had balance and harmony on all levels in yourself and your relationships? How would you spend your time, what feelings would you be experiencing. Dare to dream as if your life and health were exactly how you would like. 

Please share any additional comments: 

Loose stool or Diarrhea

Constipation 

Poor Digestion