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Filling out this pre-consultation questionaire is required prior to consulting with Dr. Graham.  The information provided will allow Dr. Graham to best address your needs.  Please take a few moments to complete the questionaire.
Demographic Information
Name
Prefer to be called
Address
Best Contact Phone
Alternate Phone
Email
DOB
Marital Status
Name of Spouse
Children
Current work
Work done most of your life
List Medical Problems
List Medications
 
Personal Information

Please answer each question honestly with as much detail as possible! This will help me help you!
Reason for Visit
What is the name of your spirituality
Level of commitment to improving or maintaining your health
How did you hear about Graham Time
What are you willing to do to improve your health
What have you already changed in your lifestyle
What do you drink daily
How often do you exercise
What type of exercise
Your Expectations of me
   
Personal Inventory

 

Personal Inventory Please be honest. Please take your time & Please think before you answer.
This will serve s a tool for measuring our progress! Answer each question using a scale of 0 to 10.

0 – Totally dissatisfied 10 – Totally satisfied.

 
Relationship with CREATOR Happiness and Joy
Overall Health Sense of Purpose
Perception of Self Time with Nature
Time with Family Sleep Quality
Ease of Movement How Loved you Feel
Expression of Love Relationship with Children
Relationship with Spouse Satisfaction with Future
Satisfaction with Self
Satisfaction with Friends
Satisfaction with Work
Place of Worship
Harmony
Clarity of Thought
Peace of Mind
General Health
Time for Self    
       
   

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