Please complete this form with as much detail as you need to. When seeing any practitioner, myself or another, your best course, as a client, is to tell me everything, and allow me to sift through the data for important points. Things that may feel incidental to you may actually be critical clues.

Please be factual! If you drink six cups of coffee a day, please don't tell me you only have two. I am not judging, but I'm employed, by you, my client, to figure out what is happening and affecting your health, and without accurate information, I simply can't be as effective in serving you.

Al information posted here becomes a part of your private clinical record, and once transcribed from here to my clinical system, your response (here) will be permanently deleted.

If you have scans, files, or other digital records for me, you will have a chance to upload those at the end of this form.