Intake Questionnaire Form
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
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?
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?
How is your concentration Focus?
Bowel type (select all that applies).
Is your weight stable or up and down?
Menstrual Cycle (select all that applies)
Birth control pills?
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?
Should be Empty:
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