Professional Documents
Culture Documents
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Please indicate if any of the following pertain to you: (indicating yes does not
make you ineligible for treatment,
however, it may restrict some of your treatment
modalities)
____high blood pressure ____seizures ____pacemaker ____blood-thinning meds
___pregnancy ____Surgically implanted joint/bone replacement or stabilizers
Please list any pharmaceutical medications that you are currently taking.
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
What brings you home to yourself? What do you find most centering? (dancing, singing,
painting, hiking, helping other people, listening to a friend, etc)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you aware of mood changes, ups and downs? Are you reactionary? A victim of your
emotions?
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you capable of easily expressing your emotions/thoughts etc?
___________________________________________________________________________________________
___________________________________________________________________________________________
Are there any emotional states / moods that you experience predominantly? (anger,
depression, etc.)
___________________________________________________________________________________________
___________________________________________________________________________________________
What is your favorite climate/weather?
___________________________________________________________________________________________
What is your favorite color?
___________________________________________________________________________________________
Do you prefer a certain genre of music, favorite band/song/instrument?
___________________________________________________________________________________________
___________________________________________________________________________________________
If you could do anything you wanted as a career what would it be?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What are your hobbies/pleasures?
___________________________________________________________________________________________
___________________________________________________________________________________________
What are your indulgences?
___________________________________________________________________________________________
___________________________________________________________________________________________
Have you ever abstained or quit anything?
___________________________________________________________________________________________
___________________________________________________________________________________________
How many hours do you usually sleep per night?____________________
Nutrition
How do you feel about your diet/eating habits?
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you struggle with willpower?
___________________________________________________________________________________________
_______________
_______________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(Are you aware of the ingredients in each one of your food items? Do you chew your
food well? Do you
breathe well while eating? Do you stop eating before bed? Do you
eat to sustain your life or to satisfy
cravings?)
Please describe a typical days diet for you:
Breakfast
Lunch
Dinner
Snacks - how often/times?