Intake Questionnaire Form

Name *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Blood type

A B AB O

Date of Birth *

Date

Weight *

Height *

Occupation *

Past Experience With other practitioners (I.E. chiropractor, Naturopath, Therapist, Homeopath, Message) *

List One to five health goals you would like to attain for yourself, in order of priority: (How long have these been a concern to you?) *

"I haven't felt well since"- *

What do you believe or suspect the reason for your condition? *

Recent Diagnosis: *

Surgeries: (with date please)

Past conditions or other health information you would like me to know with dates. Include childhood illnesses. *

List any Vaccination you have had including flu shots.

What physical trauma/ accidents have you experienced? *

Family Heath History *

List any medications you are taking now or have in the past *

List any supplement you are currently taking *

What is your daily consumption of: *

Do you/ or did you smoke?

Allergies that you know of *

What foods do you crave? *

Exercise:

How is your concentration Focus? *

Bowel movment *

Bowel type (select all that applies). *

Bed Time: *

Is your weight stable or up and down?

Constantly dieting?

Women Only: Menstrual Cycle (select all that applies)

Women only: Last period?

Women Only: Birth control pills?

Hormone replacement? *

Frequent urination? *

Prostate enlargement?

Teeth: *

Tattoos?

Previous occupation(S)?

Do you have high stress job or stressful relationship situation? *

What emotional trauma/ events have you experienced? *

What do you do to manage / relief your stress? *

What are your hobbies? Now and previous? *

Do you use? And for how long? *

Where have you lived?

How old is your home?

Remodeling/ Construction/ New carpet/ Paint?

Are there hydro lines or transformers near your home or work?

What could get in the way of your pain of action? *