How did you hear about me?
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Social media
Google search
Word of mouth
Professional referral
Other
Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
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Country
(###)
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Date of birth
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Age
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Occupation
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Marital status
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Select
Single
Married
Widowed
Divorced
Separated
Registered partnership
Other
Medical practitioner
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Name and clinic
Background
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List previous traumas, illnesses, surgeries, (incl. date and year)
Presenting issues and symptoms
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Other therapies you have experienced for this problem/condition
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Pain
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List any painful areas with their degree of pain, for example: Neck=6, Headache=4, Eyes=3
Emotions experienced at present
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List your current emotions and their strength, for example: Worry=8, Sadness=4, Regret=3
If there was one thing you could change what would it be?
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Prescription drugs
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List current and recent medications
Recreational drugs
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List current and recreational drugs
Herbs and supplements
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List any herbs and supplements you take regularly
Menstrual cycle
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If applicable, please describe your menstrual cycle, for example: 8 days regular
Exercise
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Allergies
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Intolerances
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What is your current stress caused by?
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Diet
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Do you follow any particular dietary belief? for example Paleo, Anthony William, Fruitarian, Blood group diet, Sandra Cabot...
Mother
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How would you describe your relationship with your mother? and what emotions do you feel toward her?
Father
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How would you describe your relationship with your father? and what emotions do you feel toward him?
Partner
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How would you describe your relationship with your partner? and what emotions do you feel toward them?
Children
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List your children and their age, for example: Kate=9, Tex=4,
