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Katherine Galligan

katherinegalligan.com

KatherineGalligan

Inspiration | Transformation | Evolution

Returning Client Form

Please fill out the following form to the best of your knowledge to help me understand the condition of your health.

First Name

Email Address

Last Name

Phone

Today's Date

Please explain any significant updates to your health since our last visit:

Are you currently diagnosed with a medical condition or injury?

Yes

Please explain:

What are your main objectives for your health?

I accept terms & conditions

Thank You! Please take some time to explain your current health picture. List any significant illnesses, surgeries or procedures and life events, including dates. No detail is insignificant.

Please list any prescribed medications you are currently taking, the dosage and frequency.

Please list any supplements you are currently taking,

Please upload your most recent lab results, if applicable. This is not required for box subscriptions.

Upload File

Face picture (Max 15MB)

Tell me how your diet has been? Have you been able to incorporate some of what you've learned of Ayurveda?

How have you been sleeping?

How has your digestion been? Please check any that apply:

Do you experience excessive gas?

Do you experience bloating after meals?

Acid reflux?

Heartburn?

Heaviness after eating?

Abdominal distension?

Belching?

Sleepiness after eating?

Nausea?

Vomiting?

Please elaborate on the state of your digestion:

Please check areas that are giving you an issue:

Head or headaches

The area of the neck

Anything to do with the eyes

Anything to do with the ears

Sinuses

Respiratory system

Chest or heart

Digestive system

Kidneys or bladder

Joints or muscles

Nervous system: numbness, tingling, tremors, dizziness

Circulation

Issues with the skin

Reproductive system

Endocrine system/hormones

How has your mental and emotional state been? Please check any that apply:

High stress level

Anxiety / worry

Fearful

Grief or sadness

Depression

Excessive anger

Resentment

Highly critical (of self and others)

Easily aggravated

Perfectionistic tendencies

Procastination

Self sabotage

Overcommit / overschedule

Difficulty slowing down

Difficulty expressing feelings

Trouble forgiving of self and others

Frequent guilt

Feelings of shame

Trouble saying, "no."

Trouble setting boundaries

Difficulty finding joy

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Katherine Galligan

Returning Client Form

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