EmailMe Form - Moon Yoga New Client Form

Name
Date of Birth
Phone
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Please state the primary reason for this visit. Include when you first noticed this state, any stressors occuring at the time, what brought it on and any activities that worsen/improve the situation.
Does this condition interfere with any of the following?
Sleep
Digestion
Elimination
Recreation
Work
Sex
Mood
Energy Level
Have you experienced massage or bodywork before? If yes, what type/s?
Are you currently seeing any other health care providers? If yes, please list by profession and reason you are under their care. For example "Naturopath - Fertility".
Please list any medications, supplements, herbal medicines and/or homeopathic remedies that are currently on.
Please list any allergies, intolerances or sensitivities you may have.
Please list any surgeries, hospitalizations, accidents, traumas, falls, diseases and/or any other major health events in your history.
Please describe your exercise/self-care routine and spiritual practice if applicable.
Are you regularly exposed to or consuming any of the following?
Alcohol
Cigarettes/Cigars
Recreational Drugs
Gluten
Processed Sugar
Mold
Drycleaning Chemicals
Strong Household Cleaners
Occupational Chemicals
Pesticides/Herbicides
WiFi
Caffeine
Energy Drinks
Have you ever been diagnosed with a psychiatric disorder (including eating disorders?) If yes, please elaborate and include any treatment/counseling you may have received and your experience of the treatment.
Please list any conditions/diseases that run in your family. If any parents/grandparents are deceased, please list cause of death.
Please describe anything you know about your own gestation and birth, including your mother's experience of it.
Please describe your diet. Elaborate on any foods you avoid and why. List your usual meal times, including snacks, any cravings and how much water you would generally consume on a daily basis.
Please describe your elimination pattern. Include how often you have a bowel movement, whether the stools float/sink, are formed/watery, their coloring and if any constipation/blood or mucus are present, your general comfort levels during a motion and any other other relevant information.

Please select any symptoms that apply to you:

	Past	Present
Headaches/Migraines
Asthma
Cold Hands/Feet
Skin Disorders
Swollen Ankles
Frequent Colds/Sinus Conditions
Seizures
Loss of Taste/Smell
Painful/Swollen Joints
High Blood Pressure
Low Blood Pressure
Pins and Needs in Hands, Arms, Legs or Feet
Spinal Conditions
Anxiety
Depression
Sleep Disturbances
Fainting Spells
Loss of Memory
Varicose Veins/Hemorrhoids
Muscle Tension
Herniated/Bulging Discs
Abdominal Hernia

Do you currently have any communicable diseases? Please elaborate.
What is your general opinion of yourself?
Please list and describe and goals you have around your health/well-being which you would like to achieve over the next twelve months.

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