Client Intake Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Mobile number
Vänligen skriv ett giltigt telefonnummer.
Format: (000) 000-0000.
What is the reason for your visit? How can I help you? How long have you had the symptoms/issue?
Do you have any medical conditions? (year, type) Heart and cardiovascular, cancer, chronic illness, auto-immune illness, neurological diagnosis, eating disorder, diabetes etc
What have you had tried to cure this condition/illness? Treatment, medicine...?
Do you have any allergies or asthma? (year and type)
Had you experienced any episode of epilepsy?
Yes
No
Do you have hypertension?
Yes
No
Are you currently under any medication, supplements, herbal medicine, homeopathy?
Yes
No
Please list the product names, dose and how long you've taken them for?
Did you undergo any surgical operation?
Yes
No
When did you had the procedure and what is the reason?
Have you had any injuries? (year and type)
DIGESTION - do you experience any of these symptoms?
Gas
Bloating
Diarrhea
Constipation
Acid reflux
Nausea
Lack of appetite
Over eating
Other
SKIN - do you experience any of these symptoms?
Sensitive skin
Acne
Oily skin
Dry skin
Eczema
Rash
Psoriasis
Irritated
Fungus
Abscess
Other
Where on your body do you have the symptoms?
JOINTS/MUSCLES - do you experience any of these symptoms?
Pain
Rigidity
Lack of strength
Inflammation
Cramps
Restless leg syndrome
Other
Where on your body do you have the symptoms?
CIRCULATION - do you experience any of these symptoms?
Hands/feet get easily cold
Hands/feet get easily blue
Hands/fee get easily warm
Water retention
Varicose veins
Other
IMMUNE SYSTEM - do you experience any of these symptoms?
Prone to infections
Catch colds easily
Easily contaminated by others
Other
JOB /STUDIES - enjoyment
Good
Medium
Bad
FAMILY SITUATION - civil status, children (if so how many and how old)?
SLEEP
Regular
Deep
Wakes up easily
Doesn't sleep through the night
Issues falling asleep
Issues waking up
Other
ENERGY LEVEL
High
Medium
Low
MIND & EMOTIONS Please fill out the table and select if you have the following
Rows
Yes
No
Remarks/Notes
Bad memory
Lack of concentration
Difficulty to make decisions
Gets easily tired
Migraines
Headaches
Nervousness
Fatigue
Anxiety
Depression
Low self esteem / self confidance
Phobia/fears
Worries
Mood swings
Irritability
Anger
Negative/dark thoughts
Other
WOMEN HEALTH
Are you pregnant
Yes
No
Are breastfeeding?
Yes
No
Do you take any contraceptive, if so which one and since when?
Menstruations
Regular
Irregular
Short
Standard
Long
Heavy flow
Standard flow
Light flow
Painful
Other
Cycle length in days (for ex 29)
PMS symptoms
Irritable
Worried/anxious
Mood swings
Depressed
Tired and low energy
Sleep issues
Swollen
Tender breasts
Headaches
Belly/tummy pain
Constipated
Diarrhea
Other
When did these symptoms start?
Perimenopause / menopause symptoms
Hot flushes
Night sweats
Vaginal dryness
Sleep disturbance
Mood swings and irritability
Anger
Depression
Headaches
Weight gain
Dry/itchy skin
Low sex drive
Need to urinate more often
Osteoporosis
Increased PMS symptoms
Irregular cycles (shorter or longer than they used to be)
Other
When did the symptoms start?
If you're menopaused, since when?
Do you have other hormonal symptoms or conditions (endometriosis, fibroids, PCOS, yeast infection, urinary infection, etc)
Anything else I should know about?
Date Signed
-
Month
-
Day
Year
Date
Submit
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