Intake Questionnaire Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ABABO

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?*