Therapy Inquiry Worksheet
Your Name:
Age:
Address:
Email:
Phone Number:
Fax Number:
How did you hear about us?:
1. List all the prescription drugs you are presently taking and the reason you are taking them:
2. List all the over-the-counter drugs you use on a regular basis and the reason you use them:
3. List all the nutritional supplements you use and the reason you use them:
4. Sit someplace quiet with a pencil and paper (without TV, radio, music, etc.). Mentally go over yourself from head to foot, writing down anything you notice about your body that would tell you you do not have perfect health. This would include anything you have noticed in the last month. This should include skin conditions, lumps, soreness, pain, irregular bowel habits, or anything that is irregular.:
5. Please state a medical doctor's diagnosis of any condition you have: