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Life After Christ
Home
About
Books
Prison Ministry
Testimonials
Contact
Tessa Ashford
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Intake form
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1. What is your chief complaint?
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2. How long has this been happening?
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3. How satisfied are you with your digestion?
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4. How satisfied are you with your weight?
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5. Do you ever have gas? How frequently, and what part of the day?
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6. Have you ever taken antibiotics? Which ones, how long, and when:
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7. Please describe your morning routine:
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8. Please describe your diet:
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9. Please list all supplements you are taking:
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10. Please list the ones that have helped, and for what:
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11. Please list any and all medications you have taken in your entire life:
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12. Please list any conventional medications you are currently taking:
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13. Please list any medical diagnosis:
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14. Please describe what types of doctors you are currently seeing:
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15. How often do you have appointments with them?
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16. How have they been able to help you?
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17. Do you have access to testing your bloodwork?
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18. What is your occupation?
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19. How many hours a week do you work?
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20. Do you like your job?
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21. Please describe any trauma that may have taken place in your life:
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22. Please describe your family life:
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23. Is there anyone in your life that you need to forgive?
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24. Describe your level of fear on a daily basis from 1-10.
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