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TOTAL WELL-BEING
PRE-APPOINTMENT ASSESSMENT

Soma Essential Healing
Telephone: 330-623-7388, Ext. 23
Soma Essential Healing Wellness Center
841 Boardman-Canfield Rd, Suite 302
Boardman, Ohio 44512

This secure form is to be completed and submitted online, before your scheduled appointment date. Complete all areas of the assessment. If you don't have an answer to a particular question or are not sure, leave it blank for now. This is an initial assessment. Additional information will be gathered in your pre-session interview. **This information is confidential, between you and your practitioner, and is not shared with any other parties, nor is it subject to HIPPA reporting procedures. You will be contacted by an SEH certified practitioner in your region.


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Your Information Here. (all fields are required)
Your Full Name
Enter Best Contact E-Mail Address
Re-enter E-Mail Address
How Old Are You?
Best Contact Telephone Number
Date of Assessment

GENERAL/INTRODUCTORY

Tell us what your goals are for healing and total well-being



What brought you to this appointment?



What is it that you heard or read
that made you decide
to seek out healing and total well-being?


Have you had any previous experience working with
a holitic practitioner or specific healing modality?


Briefly describe any previous experience you've had with
holistic nutrition and/or lifestyle medicine.


YOUR PHYSICAL BODY


Describe any difficulties and symptoms you are having.


What do you feel the root cause of those difficulties/symptoms is?

MEDICAL CARE

Are you currently under a doctor’s care? If so, for what?


Are you in therapy of any kind right now?


What does healthy mean to you?


MEALS/EXERCISE


Tell us about what you eat everyday.


Describe your eating habits.


How many glasses of water do you drink each day?

Do you drink tea or coffee?

Tea
Coffee

If so, What kind and how many cups per day?


How much sugar do you consume each day?


Do you smoke Cigarettes/Cigars?

Yes
No

Do you drink soda, diet soda,
other soft drinks, fruit juices?

Yes
No

If Yes, How many glasses per day?


Are you vegetarian or a meat eater?

Vegetarian
Meateater

If Vegetarian, Are you Vegan?

Yes
No

Do you consume fresh fruit
and vegetables on a daily basis?


Do you eat whole grains? If so, how often?


How many meals do you take each day?


How often do you cook
for yourself vs. eating out?


What condiments/spices do you take with your food?


Do you drink alcohol?

Yes
No

Are you taking any prescriptions drugs
at this time and, if so, what?


Do you take vitamins, herbs or other supplements
on a regular basis and, if so, what?


Do you exercise regularly?

Yes
No

Answer if you are over 40 years old:
Do you get an annual physical?

Yes
No

YOUR EMOTIONS

How do you deal with stress?



What have you observed are your coping mechanisms?


What are the top 3 emotions you feel
the most throughout your day?


YOUR MENTAL STATE

On a scale of 1 to 10
(with 1 being the least and 10 being the most)
how restless would you say your mind is?



Do you find that you are easily distracted?



Are you prone to reach for
outer stimulation from people, places
and things to feel comfortable
and satisfied?
Yes
No

List the top five things that
you crave regularly.



Do you seek the attention and approval
of others before making decisions?




What are your favorite distractions?




SPIRITUAL POWER


Do you have a spiritual life and,
if so, describe it?



Have you ever meditated or chanted before?

Yes
No

Do you have an established,
daily spiritual practice?

Yes
No

If yes, describe your
daily spiritual practice and list
the benefits your derive from it.