Robin Rose Bennett  

PO Box 367, Hewitt NJ   07421
973-728-5878

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Client Questionaire

In order to make the best use of our time together during your appointment, please answer the questions below to the best of your ability and send your information to me by clicking on the submit button at the bottom of the form. If you can't fill it out in advance of our appointment, please bring a copy with you for me to keep.  Please feel free to add in any relevant or even seemingly irrelevant information that you want me to know or that you think may be helpful.  Take as much (or as little) space as you need.  I look forward to meeting with you.

                                                                                 Green Blessings,

Robin

Please provide the following contact information:

Name
Address
Address
Work Phone
Home Phone
FAX
E-mail

Please identify and describe yourself:

Name
Date of Birth
Sex Male Female

Tell me the story of your health and health challenges/illness, including your history, and especially any recurring illnesses or challenges. Start from the past and go forward or from the present and go backward.  Feel free to include any of your family history in this story.


What is your perspective of what is going on with you and your health now, including, if you have explored this at all, any emotional/spiritual connections you may have made?


What are you told (by your doctor or other advisors or practitioners) is going on with your health? Where and how does it differ with or match your own sense of what's happening?


What are your priorities in terms of addressing your symptoms, use of pharmaceutical medications, and/or any chronic conditions?


What do you eat and drink, over the course of one week for example?  What level and type of physical activity do you engage in?  How well do you generally sleep?  Please describe these three areas in detail.


What do you take on a regular basis, including pharmaceutical or recreational drugs, vitamins, supplements or herbs?


What do you want or hope for? What is the best result you can imagine coming out of our work together as you work with your herbs?


Robin Rose Bennett client questionaire
Revised: 07/15/08

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