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New Client Form Part 2

Comprehensive Health & Lifestyle Questionnaire

Part 1 of 6 — Current Health Information

Please complete this form as accurately and thoroughly as you can. Your responses help me better 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.

Full Name

Email Address

1. Are you currently under the care of a physician, specialist, therapist, or other healthcare provider? Please list the provider type and the reason you are seeing them.

2. Have you been diagnosed with any health condition(s), past or current? Please include the approximate date of diagnosis, if known.

3. Have you had any major surgery, hospitalization, serious illness, injury, or infection? Only include issues that are recent and/or still relevant to why you are contacting me.

4. Do you have any medication, food, herb, supplement, latex, or environmental allergies or sensitivities? Please describe the substance and your reaction.

5. Please list all current medications, over-the-counter products, herbs, vitamins, and supplements. Include product name, dose, frequency, and why you take it, if known.