Short Client Intake Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Post codeCountry

Date of Birth

DayMonthYear

Place of Birth (Town/City & Country)

Sex

E-mail

Phone Number

Area CodePhone Number

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If you are completing this information on behalf of someone else please provide your name, relationship to the client, and your contact details.

How did you find out about Funky Forest Health & Wellbeing?

What type of therapy are you seeking?

Is your request to see a specific therapist? If so, who?

Click to select, or leave blank if n/a

Have you been referred to our practice by another health professional? If so, please provide their name.

Is your availability to attend appointments limited? If so, please note your general availability here. (Please be aware that our after hours availably is limited and may require a longer waiting time for an initial appointment).

Occupation

Do you have a regular Medical Doctor (GP)? If so, please provide their name

GP's Phone Number

Area CodePhone Number

Are you under the care of any other health professionals? If so, please provide their names and professions

Your Health Profile

Please briefly outline your reasons for seeking therapy and/or desired goals of therapy

Major complaints (please list in order of priority). These may be in addition to your primary reason for seeking therapy above. Please indicate for how long you have had these problems e.g: crash dieting 10 years, eczema 3 years.

Health Problem 1

Health Problem 2

Health Problem 3

FAMILY HISTORY

Partner?

If Yes, Partner's name and age?

Children?

If Yes, how many and ages?

Family history health issues (circle all that apply, going back to grandparents)

If other, please describe:

NUTRITION

Do you have any concerns about your diet or eating patterns? Please explain.

What are your biggest OBSTACLES to healthy eating?

What foods do you commonly eat for BREAKFAST?

What foods do you commonly eat for LUNCH?

What foods do you commonly eat for DINNER?

What foods do you commonly eat for SNACKS?

What foods do you DISLIKE?

What foods are you INTOLERANT OR ALLERGIC to?

What are your FAVOURITE foods to eat?

Food/Ingestion: Please mark if you eat, drink, or use any of the following

Rows	Daily	Often (2-5 times a week)	Sometimes (1-2 times a month)	Never
Alcohol
Artificial sweeteners
Lollies
Chewing tobacco
Cigars or cigarettes
Coffee
Black tea
Carbonated drinks
Diet drinks
Fast food
Fried foods
Margarine
Stimulants (Herbal or drug)
Depressants (Herbal or drug)

Comments on any of the above?

What is your experience with dieting? (Are you a dieter? Have you had success with diets?)

Body Weight Details

Current body weight (kg)

Current height (cm)

Body Mass Index (if known)

If you are currently under your healthy weight range, and you are seeking therapy for an Eating Disorder please note your current BMI above (or your height and weight here), and any medical concerns. (This information is required as we are not able to accept referrals from clients with a very low BMI or who are medically compromised)

Describe briefly any significant weight changes throughout your life

How would you describe your relationship with your body?

Elimination Patterns

Number of bowel movements per day

Odour?

Colour?

Other comments

Menstrual and Pregnancy History (For Women)

First Menstrual Period (Age)

Number of Pregnancies (Please indicate if full-term)

Please state if you are peri- or post-menopausal, and what age you reached menopause if applicable

Describe the general nature of menstrual cycles (e.g. regular, cycle length (in days), easy, difficult, heavy clotting, emotional, etc.)

LIFESTYLE

Describe your general life balance – is your lifestyle harmonious or imbalanced and why?

What are your major sources of imbalance?

Comments on any of the above?

How do you help bring your life into balance? Please select all that apply from the dropdown menu.

What is your general energy level most of the time?

Describe briefly what gives you energy and what takes it away.

GIVES me energy:

TAKES my energy:

Which of the following most describes your thought pattern?

Comments on above thought pattern?

How active are you?

What type of physical activity do you do and like to do?

Other comments on activity / exercise?

How do you normally eat? E.g. in a hurry, on the run, sit down family style, by yourself?

Amount of Sleep

How many hours do you typically sleep every night?

Quality of sleep?

Do you feel refreshed upon waking?

Please list any medications or dietary supplements not listed above that you are currently taking.

Recent significant biomedical results / blood pathology in last 3 months (e.g. Cholesterol, HbA1c, Fasting Blood Sugar)

Hospitalisations/Surgery: Please provide month/year with brief description.

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