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Bonnie Roger’s Client Health Questionnaire

In order for me to have a better understanding of you prior to our appointment, I respectfully request that you fill out this form and email it to me at bonniesherbals@gmail.com (The best way is to copy it and then paste it either into a word document or directly into an email) You can use as much space as you need for each question.  I recommend that you fill it out, store it in your computer for a few days and then go back and re-read what you wrote, you may find things you would like to change.  The other thing is if as you are writing, if something keeps popping up in your mind which you think has nothing to do with anything, write it down as it may become clear to you that there is a certain connection later on.

If this is too overwhelming for you than don’t worry about it and we will cover all the information when we meet.  Just make sure to bring along with you any supplements or pharmaceuticals that you are on.

I look forward to working with you.

Bonnie

 Please provide the following information:

 Name:

Address:

Work phone:

Home phone:

Cell phone:

Fax:

Email:

Date of birth:

1.    Tell me the story of your health and health challenges/illness, including your history, and especially any recurring illnesses or challenges. Start from the past and go forward or from the present and go backward.

2.    What is your perspective of what is going on with you and your health now, including, if you have explored this at all, any emotional/spiritual connections you may have.

3.    What are you told (by your doctor or other advisors or practitioners) is going on with your health? Where and how does it differ with or match your own sense of what's happening?

4.    What are your priorities in terms of addressing any symptoms and/or any long-term condition, if any?

5.    What do you eat and drink, for example, over the course of one week? (please write up a minimum of 2 days of a food diary – preferably 5 days, in a separate document, or at the end of this one)

6. What level of physical activity do you engage in? 

 6.   What supplements or medications do you take on a regular basis?  Be sure to include pharmaceutical or recreational drugs, vitamins, supplements or herbs? (be as specific as possible)  Are there any allergies that I should be aware of?

 7.   What do you want or hope for? What is the best result you can imagine coming out of our work together as you work with your herbs?