| Name | |
| Age | |
| Gender | |
| E-mail Address | |
| State/Country | |
| What brings you to The Holistic Dragonfly? | |
| Please explain. | |
| Height | |
| Weight | |
| What is your primary health concern? | |
| Have you had any major illnesses, injuries,
and/or hospitalizations? If yes, please explain. | |
| Do you suffer from allergies? If yes,
please explain the allergy and the symptom. | |
| Do you take medications, vitamins, and/or
supplements? If yes, please list and describe the reason. | |
| Do you smoke? | |
| Do you consume alcohol? | |
| How often do you exercise? | |
| What forms of exercise do you enjoy (even
if you don't do it as often as you think you should)? For example, yoga, martial arts, sports, etc. | |
| List any Alternative Therapies with which
you are currently involved? For example, Chiropractic, Massage Therapy, Acupuncture, Reiki, etc. | |
| How would you describe the stress level in your life? | |
| Do you think you have a balanced nutrition plan? | |
| What is your favorite food? Do you have
any special dietary needs? If yes, please explain. | |
| What is your religious and/or spiritual belief? | |
| Do you meditate? | |
| List any major health conditions (high
blood pressure, diabetes, heart problems, etc) of your mother. | |
| List any major health conditions (high
blood pressure, diabetes, heart problems, etc.) of your father. | |
| Are you willing to make changes in your diet, fitness
routine, stress level, and current condition? | |
| Please describe what you hope to receive
from your experience with The Holistic Dragonfly. You may also use this space to include any other information and/or questions
you have for the Consultant. | |
| |
