Client Health FormPlease fill out and submit at least 24 hours in advance of your appointment. Thank you! Patient Number * Reason For This Appointment * I Am Open To/ Interested In: * Constitutional Homeopathic Care Coaching/Counseling Human Design Attunement Any/all of the above, as Jane sees fit Current or ongoing mental/emotional issues * Depression, Anxiety, Mood Swings, Anger Outbursts, etc...? You may also include here communication and/or relationship issues. Current or chronic physical issues or ailments * Do you have any current or ongoing issues with the following? (We will cover in detail during your appointment). Skin Musculoskeletal Ear/Nose/Throat Respiratory Urinary Reproductive (Incl Menstrual, Prostate, etc) Circulatory/Cardiovascular Other None of the above How is your sleep? Please list any medications or supplements you are currently taking: * Please list any allergies or sensitivities (including food): * Please list typical tobacco, alcohol, or recreational drug use, if applicable: * Hobbies + Interests: Thank you!
