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 planning 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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