Please answer these questions as accurately and with as much information as you can in order to assist me in providing you with the services that suits your needs as much as possible.

By accepting this document, I agree that the confidential information in this questionnaire and the information contained herein will not be disclosed to others. 

Personal Information


Do you have children?

Health Information

Is there a history of illness in your family?

Do you have or have you had any health problems?

Have you had any injuries?

Are you taking any medication?

How is your appetite?

Do you have any allergies? (especially to the skin)

Are you pregnant?

Health Information

Do you smoke?

Do you drink alcohol?

Do you have difficulty sleeping?

Do you feel rested when you wake up?

Have you had any major stresses in the last 12 months?

Do you practice any relaxation techniques?

Do you feel you are able to cope with stress in your life?

Have you suffered major trauma – physical or emotional?

Do you have a good support system in your life?

Spiritual/Emotional Health

Do you practice any spiritual techniques such as meditation, church, or other?

Do you practice self care?

Do you have any hobbies?

Which of the following categories do you feel you need help in (you can answer more then one):

Which style of jewellery do you like to wear (you can answer more than one):

By signing below, I certify that I have read and answered each question in this questionnaire as accurately as possible.