SolFuzion Client History

Name*

First NameLast Name

Age*

Birthday (optional - used for astrological data)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

Phone Number*

Please enter a valid phone number.

Family GP*

Include how long you've been seeing this GP.

Other health professionals you see*

Include their name, profession and how often and long you've been seeing them.

Occupation, if recent what was it previously?*

Include how long you've been doing this

Spouse/Partner

Include Age and Gender

Children name age gender

Include Name, Age and Gender

Siblings

Include Name, Age, Gender and Relationship.

Your place in family

Parents

Include Name, Age, Relationship (if deceased include age YOU were when they passed)

Childhood Traumas and Illnesses*

*if you're able, be specific with age, areas of body and activity involved for each event.

Adult Trauma 18+ (emotional trauma, accidents, surgeries and major illnesses)*

*if you're able, be specific with age, areas of body and activity involved for each event.

Current Conditions/Injuries/Pain*

Describe where on the body, what makes it worse and intensity (eg; 6/10)

Current Medications*

Name and why you take it.

Current Supplements*

Name and why you take it.

Daily Intake (How much are you consuming on average?)*

Daily Diet (and Sensitivities)*

Exercise Routine*

Describe your current sleep habits*

Usual bedtime, average duration of sleep, wake up times, how rested do you feel on waking?

List your strengths or things you like about yourself.*

List your weaknesses or things you dislike about yourself.*

Are you currently pregnant?*

Do you have a pacemaker?*

Are you epileptic or have a family history?*

What services are you interested in?*

Reasons WHY you are here? *

What issues/goals do you want to work on?*

What outcome would you like to experience? How do you want to feel after session?*