Z-Health Intake Form

Z-Health Intake Form
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date *

Month Day Year
Date
Birthdate *

Month Day Year
Date
Occupation
Is there anything you would like to do that you are currently unable to? If so, what is that? *
What are your goals in us working together? *
How would you be able to tell that this partnership has been successful? *
Health History Questions
Do you currently have any medical diagnoses? If so, please describe. *
Are you currently taking any medications? If so, please describe. *
Do you have any of the following (check all that apply):

Scars Peripheral neuropathy Nerve damage Tatoos None
Please explain as best you can the event(s) resulting in the above.
Do you currently experience any of the following (check all that apply):

Weakness Joint pain Joint instability None
If so, please describe.
Have you ever experienced any of the following (check all that apply):

Whiplash Concussion mTBI Disc injury anywhere in your spine Seatbelt trauma None
If so, please describe.
Have you ever experienced any of the following (check all that apply):

Vertigo Dizziness Clumsiness Chronic back or neck tension An aversion to crowded places Prone to falling in the dark Emotional fluctuations Scoliosis A worsening of symptoms with alcohol None
If so, please describe.
Have you ever experienced any of the following (check all that apply):

High blood pressure High heart rate Arrhythmia Sweaty hands or feet (especially on one side) Slow moving digestion Light or sound sensitivity None
If so, please describe.
Have you ever experienced any of the following (check all that apply):

Chronic pain Mood swings Aching or burning pain Difficulty learning new things Cramping of hands or feet Tremors at rest None
If so, please describe.
Have you ever experienced any of the following (check all that apply):

IBS (Irritable Bowel Syndrome) Chronic GERD (Gastro Esophogeal Reflux Disorder) Eating disorder Anxiety Motion sickness Depression PTSD Chronic gut distension or bloating Inappropriate crying or laughing Difficulty swallowing Chronic immune system issues ADHD Pelvic floor pain, weakness, or incontinence None
If so, please describe..
Please Select Which Of The Following Best Describes You (check all that apply):

Difficulty with focus, especially over long periods of time Decreased attention span Difficulty making decisions Difficulty with panning and organizing Word recollection issues Difficulty with initiating tasks You enjoy taking risks You avoid taking risks Lack creativity Abundant creativity Enjoy art and music Weak core stability Postural weakness or fatigue Tightness in arms and/or legs Bladder control issues as a child or presently Difficulty following a beat Enjoys reading None
If so, please describe.
Please select which of the following best describes you (check all that apply):

Seldom or never bump into things Often injure one side of the body Hypersensitive to pain or touch Enjoy massages and bodywork Easy time reading maps No problem telling right from left History of dyslexia None
If so, please describe.
Please select which of the following best describes you (check all that apply):

You avoid noisy environments You like music with predictable rhythms You like music with unpredictable rhythms Good at keeping track of time Probably should wear a watch Hard time remembering things Can remember things easily Forget where you leave things Addresses and phone numbers are easy to remember Difficulty with names or faces Often late for appointments If you are not early, you are late History of epilepsy Lack of sense of smell Tinnitus or ringing in ears None
If so, please describe.
Please Select Which Of The Following Best Describes You (check all that apply):

Enjoys visually stimulating environments Prefers dim lighting Color blindness Likes playing ball sports Likes sports that don't use balls Would rather not play sports at all Floaters in the eyes Cataracts or glaucoma Eye surgery Wears glasses or contacts None
If so, please describe.
Injury and Surgery History
Have you ever had surgery? If so, please describe.
Have you ever had dental surgery (cavities, root canals, braces, retainer, etc)? If so, please describe.
Have you ever been in a car accident? If so, please describe.
Fuel Section
Tell me a little bit about your current diet. What do you typically eat?
Have you ever tried any other diets? If so, which ones?
Do you, or have you ever fasted regularly? If so, please describe.
Do you have a history of heart disease? If so, please describe.
Do you have a history of thyroid issues? If so, please describe.
Do you have a history of cancer? If so, please describe.
Any food sensitivities or allergies? If so, please describe.
Who are you?
What is your favorite movie?
What is your favorite food?
What is your favorite place to travel to?
What do you do for fun?
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Z-Health Intake Form

Health History Questions

Injury and Surgery History

Fuel Section

Who are you?