Health History Form
Description
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Email *
Full Name *
Address: *
Phone Number: *
Email: *
Referred By: *
Date of Birth & Time *
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/
DD
/
YYYY
Describe the physical/emotional problem(s) for which you seek help. Please include dates for when each problem has occurred:
Describe where you feel you are spiritually/intuitively: *
Past Medical history (previous injuries, surgeries, etc.) Please describe and give approx. dates: *
List medications, supplements (include OTC) that you are currently taking: *
What daily activities are you finding difficult because of the above complaints: *
Have you ever had this problem before? If so, when? *
What are your goals for healing? *
Please list any other healthcare professional you are seeing for this/these problem(s): *
Please list any medical tests you've had within the last year: *
Please check any of the following feelings you've experienced over the last few months: *
Required
My family stress is: *
My relationship stress is: *
My work stress is: *
My financial stress is: *
My health stress is: *
How much time do you have for yourself to relax? What do you do to relax? (hobbies, meditation etc) *
Do you exercise? And if so, what kind and how often? *
What does your diet consist of? Any allergens or intolerances? *
How many hours a night do you sleep? Is your sleep restful? If not, please explain.
If you wake up during the night, when?
When do you go to sleep?
When do you usually wake up? *
Please list any areas of pain and discomfot.
Rate them on a scale of 1-10.
1: slight awareness of discomfort.
10: you feel like you need to go to the emergency room *
By typing my name here, I acknowledge that all in this form is true to the best of my ability.
I acknowledge that all services provided by Cassandra Clegg do not replace medical care/treatment.
I acknowledge that Cassandra Clegg does NOT diagnose, or prescribe any types of medications or herbs.

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