Client Information Form

Thank you for filling out this form for us to enter your information into our database, so we can create your file and assist you better. Please know that all your personal information is 100% confidential and will never be released to anyone, except with your written consent.

– Daniela Fisher, Owner, Naturally Given Ltd.

GENERAL INFORMATION

Your Full Name *

Your Date of Birth *

Email Address *

Cell Phone *

Home Phone

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

EMERGENCY CONTACT

Name of Your Emergency Contact *

Emergency Contact’s Phone *

QUESTIONS

1. In what country were you born and/or grew up? *This is to understand what environmental toxins you may have been exposed to.0 / 10

2. Have you had any emotional or life traumas in your childhood or as an adult? If yes, please describe. *(Note: Even if you feel you didn’t have childhood trauma, please briefly describe how you grew up.) Also, briefly describe your relationship with your mother and father.

3. Have you had any surgeries or any current health concerns or illness? If yes, please describe. *(Note: Even if you feel you didn’t have childhood trauma, please briefly describe how you grew up.) Also, briefly describe your relationship with your mother and father.

4. How would you rate your diet, from 1 to 5?(1 = excellent; 5 = really bad)

5. Do you take any medications and / or supplements, if yes, please describe below. *

6. Do you have any current or chronic pain? If yes, please describe where and for how long. *

7. Do you have any food or seasonal allergies? If yes, please describe. *

8. Do you exercise regularly? If yes, what kind and how often? *

9. How is your stress level, from 1 to 5?(1 = excellent; 5 = really bad)

10. What is your occupation? *0 / 200

11. Are you married, single, divorce, re-married, widowed, or in a relationship? *0 / 100

12. Are you pregnant? If yes, how many months? *0 / 100

13. Do you have children? If yes, how many and how old? Did you have any miscarriages? *

14. Do you have any sleep issues? If yes, please describe. *

15. Are you right- or left-handed? *Right-handedLeft-handed

16. Describe briefly what are you looking to self-improve, and if you are willing to commit to it. *

17. How did you hear about us?0 / 200

Client Information Form

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