chosen name:

where are you located?

email

birthdate

birthtime

birthplace

place(s) of childhood:

blood type:

what are you currently doing in your life that nourishes you, brings you peace, joy, and health?

what would you like to get out of this consultation?

where in life, health, and relationships do you feel a lack of balance, joy, or freedom?

which areas of your life are you most interested in bringing balance to?

please list allergies and sensitivities:

please list any Western or Allopathic diagnosis you'd like me to know about:

list medications you have taken within the last 2 years:

what physical changes do you wish for?

how do you tend your spirit?

anything you’d like help letting go of?

hobbies, skills, and interests:

typical bed time:

typical rising time:

what were your parents doing in their lives when they had you?

was your birth premature, easy, prolonged, traumatic, at home

any past or current injuries?

serious illnesses?

hospitalizations?

when?

age of puberty?

other providers

name, specialty, contact info

any possibility of pregnancy?

last day of recent menstrual cycle?

do you use birth control?

types of foods you eat on a regular basis:

any eating routines?

how much water do you drink on average a day?

how much coffee a day?

how much alcohol a day?

how many sugary treats?

list some favorite forms of exercise:

how often do you engage in these activities?

any cigarettes?

how often do you poop?

do you feel hot or cold more often?

do you enjoy exposure to heat or cold more?

describe your dreaming:

favorite and least favorite foods:

Davida Israela Temima Melamed

raised by the Salish sea

this form is for those seeking comprehensive constitutional examination.