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NGVNS

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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Introduce yourself GVNS
1

Describe in a few sentences the problem. How does it effect you emotionally? Physically? Mentally? There are no wrong answers. Example- I am in pain, for a week now, my boss is a 🦃, when I run my leg swells and I burp nonstop after I eat cold drinks. I gained 30 Covid lbs. I hear cats talking behind my back. I can't even rest and now my doctor says I have a strange prognosis. I am seriously anxious.

2

List your Medical history-(Surgery,Diseases ,Allergies, Medications reactions) Example-I had knee surgery, a C-section, BPH , I am allergic to cats, mean people, dandelions and amoxicillin.

3

Please list all medications, essential oils, and supplements you take currently. (Example: Vitamin C, Lisinopril, Orange oil, Saw Palmetto)

4

What three foods do you eat the most? (Example:Veal, Pancakes, Oranges)

5

What is your favorite color, aroma, and animal? Example-Yellow, wood resin, 🦃

6

Who is your personal hero? (Donald Trump, Mighty Mouse, Kanye West)

7

When was your most recent life stressor? Please describe it.(Last Sunday, I stubbed my toe and fell down)

8

What is the thing you are most proud of in your life?(-Or a goal you wish to achieve) Example- I won the country fair best in show for my luxurious locks.

9

How well do you sleep?

Select one or more answers
10

What position do you sleep in?

Select one or more answers
11

Describe your family medical history, include any unusual stories of your mother's pregnancy with you or birth. Example-My Aunt had glaucioma, my mother gave birth to me in a taxi, other aunt had male pattern baldness, and my father had one testicle.

12

Last but not least, how is your pooh? Yes, the kaka, doo, doo, crap, poopy, turd stuff 😏 Don't be embarrassed from the roots to the toota -it's a human thing & you are one of us.

Select one or more answers
13

Is this your first experience with integrative therapies?

Select one answer
14

Please enter your initials

15

Have you laughed today?

Select one answer