Name
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First Name
Last Name
Email
*
Phone Number
Birth ~ Date of birth, location, how you were born if you know it! (ie. vaginal birth, c-section, premature, etc.)
*
What health or body concerns would you like to address in our work together?
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Have you been given a formal diagnosis for any ongoing health or mental/emotional health condition? (past or present)
Medications ~ Please list any medications (prescriptions and OTC) you are currently taking, dosage and frequency. Please indicate what is taken daily and what is taken as needed. NOTE: herb/drug interactions exist so it is important to include all you are taking.
Please list any medications you took for an extended period of time in your life?
Include when you stopped taking this medication and how long you took it for.
Do you have any allergies?
Do you have any food sensitivities?
Please list any supplements or herbs you are currently taking? Name, form, dosage and company you purchased from.
How often do you drink alcohol?
Please provide a background of your health history and any major life circumstances that have impacted your health, including any physical or emotional trauma that you feel comfortable sharing at this time. Start from infancy, up to present. Please list anything you feel is relevant. (If we have spoken more at length prior to filling this out, you leave this blank if you prefer.)
Please share any details you have about the health history of any person in your immediate family, including parents and grandparents.
Rate you current stress level on a scale of 1 -10 (1 being mild everyday stress, 10 being severe). What is the primary cause of the stress in your life?
Are you currently seeing a therapist or any other wellness providers?
How many hours per day do you look at a screen?
CLIENT CONFIDENTIALITY AND RELEASE ~ I understand Alicia is not a medical provider and this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions. As such, the practitioner does not prescribe medical treatment. I have stated all my known conditions and take it upon myself to keep the practitioner updated on my health. Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release from their client before taking any information about them. I give my permission to this practitioner take notes, including health history, medical and/or personal information. All information will remain private.
Date
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By writing your name below you acknowledge you have read the client confidentiality and release and that all information provided is accurate.
First Name
Last Name
