Holistic Wellness- feel, be, live well

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Holistic healthcare is most effective when the practitioner completely understands the patient’s physical, mental, emotional and spiritual concerns and conditions.

The information you provide helps me understand your needs and how to best help you reach your health goals. Your time, honesty, and thoughtfulness are appreciated. Your information will be handled with sensitivity and confidentiality. Feel free to speak with me regarding your privacy concerns or general questionnaire questions.

This form is NOT HIPPA compliant. Please do not put any sensitive health issues in this form. 

Name: *
E-mail: *
Phone: *
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Why did you choose to fill out this form at this time? *
Are you currently receiving healthcare?
What types of modalities are you interested in? *
If you chose other above, what else are you interested in discussing?
What are your most important current health concerns? List them in order of importance. *
What is your present level of commitment to addressing the underlying causes of the health problems listed above? (Rate from 0-10; 0 being little commitment, 10 being 100% committed) *
What behaviors or habits do you engage in regularly that you believe support your health? *
What behaviors or habits do you engage in regularly that you believe do not support your health? *
What do you love to do? *
What time of day is your energy best? *
If you chose other above, please fill in below
What time of day is your energy at it's worst? *
If you chose other above, please fill in below
What is your time zone? *
What is the best time to call? *