New Client Intake Form

Intake Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
Date of Birth*
Malefemale
Email
Emergency Contact - Phone*
How did you hear about us?
Please check ALL of the following symptoms, which you now have or have had in the past year. Be as thorough as possible! Your health history is strictly confidential.
General Syptoms*

HeadacheFeverChillsSweatsFaintingAllergiesDizzinessConvulsionsLoss of sleepFatigueNervousnessLoss of weightWeight GainIrritated / Itchy skinYeast / DischargeBloatingConstipationTeeth GrindingMood swingsStinky FartsDiarrheaAggressionPainful/ Inconsistent/ Heavy menstruationNoneOther
Numbness In...
Skin*

Skin eruptionsItchingBruises easilyDrynessBoilVaricose VeinsSensitive SkinHives or AllergiesAcneNoneOther
Urinary*

Frequent UrinationPainful urinationBlood in UrinePus in urineKidney troubleInability to controlFoam in UrineProstate troubleNoneOther
Respiratory*

Chronic CoughSpitting up phlegmSpitting up BloodChest painDifficult BreathingNoneOther
Ear, Nose, Throat*

EaracheEar NoiceEar DischargeNose BleedNasal obstructionChronic sinus infectionNoneOther
Cardio-Vascular*

Rapid heart beatSlow beating heartHigh Blood pressureLow blood pressurePain over heartHeart attackSwelling of anklesPoor CirculationNoneOther
Brain*

Memory LossDeclining FocusDecrease in attention spanExcessive brain fogOverly StressedShort temperedAnxietyDepressionLack of motivation to accomplish goalsConfusionNoneOther
Muscle, Bone & Joint*

Stiff neckBackacheSwollen jointsPainful tailboneFoot or ankle troublePain in: Shoulder, hips, legs, knees, feet or otherNoneOther
Check any of the following conditions you NOW have:*

Metal FillingGum troubleAppendicitisArteriosclerosisArthritisCancerChicken PoxDiabetesDiphtheriaEczemaEmphysemaEpilepsyFever BlisterColitisGoiterGoutHeart problemsMalariaMeaslesMental DisorderFluMultiple sclerosisNervous breakdownPneumoniaPolioRheumatic FeverMumpsStrokeSmall PoxTuberculosisUlcersVenereal InfectionWhooping CoughScarlet FeverSchizophreniaNoneOther
Please describe the what and when of any situation below:
Have you ever:
Constipation?
When did Constipation begin?
Have you ever been on birth control?
How many antibiotic treatments total in your lifetime?
What was the most recent medical situation or hospitalization (When/Where)?
Habits
Energy: Rate your energy level on a scale of 1-5 (5 being best) *
Energy: Where do you want your energy to be on a scale of 1-5 (5 beingthe best) *
Brain Fog: Rate your level of brain fog on a scale of 1-5 (5 being theworst)*
Attitude: Do you generally have a positive attitude? Yes/No*
Emotions: Do you have full control over your emotions? Yes/No*
Sleep: How many hours daily?*
What hours do you generally sleep *
Exercise: Do you exercise? *
Workout schedule *
Water: Do you drink ½ your body weight per day? *
Weight: Current weight - Ideal weight*
Do you eat organic? Yes/No If Yes, what foods*
Food: Too much? / Not enough? *
Do you eat processed foods? Yes/No - if yes how often?*
Do you eat gluten? Yes/No - if yes how often? *
Do you eat dairy? Yes/No – if yes how often? *
Do you eat fish? Yes/No – if yes how often? *
Do you drink alcohol? Yes/No - if yes how often? *
Do you drink coffee/tea? Yes/No – If yes how often?*
Do you smoke? Yes/No *
Do you take any vitamins or dietary supplements? Yes/No - If yes what do you take?*
Do you take any ProBiotics, Digestive Enzymes, Dietary Fiber supplements or any other digestive health supplements or prescriptions? Yes/No - If yes what do you take?*
List any medications (current or in the past year – please indicate) *
Do you take any over the counter drugs i.e. Aspirin, Advil, etc? Yes/No– if yes what do you take and how often? *
What is your primary health concern at this time? *
I certify to the best of my knowledge that the above information is accurate and that if anything changes in regards to my health I will notify someone from the Internal Harmony Team immediately.
E-Signature*

First NameLast Name
Date of Signature*
Should be Empty:

Intake Form

Habits