New Client Form Part 2

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This is Part 2 of the New Client Form. It is for anyone who wants more in-depth consideration as part of their health assessment. Please take the time to complete this form thoroughly. The more detail you provide, the better I will be able to understand your needs and make recommendations. 
> Client Responsibility & Wellness Disclaimer > Informed Consent Information Here
​Comprehensive Health & Lifestyle Questionnaire
Please complete this form if you have chosen a more in-depth consultation. Answer as accurately as you can. Your responses help me understand your current health patterns, lifestyle, and wellness priorities so that our session can be more focused and individualized. ​This form is for educational and wellness-support purposes and does not replace medical diagnosis, treatment, emergency care, or advice from a licensed medical provider.

    Part 2

    ​> Text boxes are expandable if needed
    > Leave text boxes BLANK if your answer is NO
    Current Health Information
    Food, Digestion & Hydration
    8. Describe a typical day of food and beverages.
    Include meals, snacks, caffeine, water, alcohol, and evening eating.
    Sleep, Stress & Energy
    Lifestyle & Daily Patterns
    22. Please indicate your current use of the following substances:
    Use Never, Occasionally, Weekly, and Daily as your answers ..
    Current Health Patterns
    ​23. Please check any symptoms you experience regularly or have experienced during the past 3 months.
    Family History & Additional Information
    > Please make sure you get a Confirmation page after submitting this form. If you do not, then try resubmitting to make certain it has gone through. ​