Part 1 - Please answer the following questions honestly and to the best of your ability.
Please describe the areas of your health that you would like to see improvement in, from most troublesome to least. Please include dates when each issue occurred.
History of Chemical Stressors
History of Emotional Stress: Select the severity of historic or current stressors for you. 0 = no stress, 5 = most severe:
Please indicate your CURRENT stress level in each area below.
Part 2
Please list areas of pain (i.e. right shoulder, left ankle/front side) and indicate (select) the circle that best describe the level of discomfort on a scale of 1 to 10
