RYLI Institute

Empowering You to Create a Life of Excellence

14. How many hours a night do you sleep? Is your sleep restful?

Time Zone

10. Please list any medical tests you have had in the past year.

1. Describe any problem(s) related to your current health. Please include dates when each problem began.

Date of Birth:

Health &Well Being Appointment Intake:

11. On a scale of 1-10, how high is your overall stress? Describe the source(s) of your stress: financial, relationships, job, health, etc.

9. What daily activities are you finding difficult or are limited because of your above conditions?

6. Past medical history (previous injuries, accidents, surgeries, etc. – with approximate dates).

5. If not already included in answer to #1 above, please describe any troubles you have with mental health (such as: anxiety, depression, learning disabilities, etc.)

Name: *

12. How much time do you have for yourself to relax and what do you do to relax, i.e. hobbies, meditation, etc.?

13. Do you exercise? And if so, what kind and how often?

2. If not already included in answer to #1 above, please describe any troubles you have with digestion (such as: loose stools, bloating, cramping, acid reflux, etc.).

7. List the medications (including over the counter) you are presently taking as well as any supplements you take daily.

Phone

3. If not already included in answer to #1 above, please describe any troubles you have with your muscles and joints.

Email: *

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8. Are you allergic to any medications, foods or herbs?

4. If not already included in answer to #1 above, please describe any troubles you have with your respiratory system (such as: breathing, coughs, sinuses, allergies, etc.).