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Primary health concerns

Please describe your reason(s) for seeking treatment with us:

The following questions are voluntary but the information gathered helps us treat you holistically. Please answer only what you feel comfortable to share at this time.

Current medications/supplements:

Current or former hospitalizations, surgeries, major injuries, or trauma:

Please list what & when

Allergies:

Autoimmune disorder:

Please describe where your pain is located on your body:

How severe is your pain?

Please choose a number on a scale of 1 (no pain) to 10 (severe pain)

What, if anything, makes the pain better?

What, if anything, makes the pain worse?

Please indicate your energy level over the past 2 weeks:

Choose a number on a scale of 1 (no energy) to 10 (very energetic):

On average, how many hours of sleep do you get per night?

Please list any special diets you adhere to:

Please list any foods you avoid:

Please list any foods you tend to crave:

Please describe what you typically eat for meals:

Breakfast:

Lunch:

Dinner:

Average length of full menstrual cycle:

How many days in between your periods

How many days does bleeding typically last?

Current method of birth control:

Total number of pregnancies:

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