Client Symptom Information

Please fill out the following forms and Dorothea will contact you to set up an appointment. Thank you!

Name: Age:
Address: City:
State: Zip Code:
E-mail Address: Phone Number:
What other health practitioners have you worked with?
Do you meditate or practice any other type of relaxation? Yes   No
If so, please list them.
Number of Children:
Spouse's Name:
Please list any surgeries and serious illnesses.

Symptoms or conditions:

low energy/tired feeling skin problems headaches/migraines cuts and bruises
aching joints muscle cramps stress colds/infections
high or low blood pressure desire for sweets concentration problems depression
difficulty sleeping or waking up cold hands/feet bloated/ gas/ indigestion constipation
diarrhea allergies/sinuses poor night vision varicose veins
hemorrhoids menopausal symptoms

Emotional symptoms:

fear worry anger sadness

Major illnesses of your parents:

Any additional problems, questions, or comments: