lightkeeperchiro.com - Intake Form

Intake Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Current Medical Conditions, Disorders and Diseases - Please check all that apply

CancerSurgically implanted ElectroStimulation Devices (Ex: Pacemaker)AutoimmuneCardiovascularUse of Medication that Cause Photo-SensitivitySkinVascularTattoo with Metallic InkEating DisordersPregnant/NursingEpilepsyGastric Bypass/SleeveInsulin Dependent (Diabetes)Endocrine SystemNone of these
Check all symptoms that have applied to you in the last 60 days

FatigueIrritable BowelDepression/AnxietySleeping DifficultiesConstipationHeadaches/MigrainesRestricted ActivitiesLeg/Foot PainHigh Blood PressureShoulder/Arm PainInability to Lose WeightBack/Neck PainStressDigestive ProblemsIrritableNone of these
Personal Goals

Change your Body (Lose weight, fat, and/or inches)Sleep BetterMore EnergyLower Blood PressureReduce StressMore Confidence in your AppearanceLower A1COther
Areas of Concern
Which program(s) are you interested in?

Weight Loss, Inch Loss and/or Fat LossCellulite EliminationStretch Mark FadingSkin Tightening
If you checked Weight Loss, Inch Loss and/or Fat Loss above, how much weight would you like to lose?

10-20 pounds30-40 pounds50-60 pounds70-80 pounds90 or more pounds
If you checked Cellulite Elimination above, which area(s) would you like to address?

ThighsHipsButtocks
If you checked Stretch Mark Fading above, which area(s) would you like to address?

AbdomenHipsButtocksArms
If you checked Skin Tightening above, which area(s) would you like to address?

AbdomenArmsNeckThighsHipsButtocks
Please answer the following questions
Age
Height
Current Weight
What was your weight 1 year ago?
What was your weight 5 years ago?
How much did you weigh when you were most comfortable with yourself?
What has had the biggest impact on your current weight condition?
Over your lifetime, how many diets/exercise programs have you tried?

None1-34-67 or more
What diet/exercise programs have you tried?
Do you smoke?

YesNo
If yes, how many packs per day?

0-12-34 or more
Do you drink alcohol?

YesNo
If yes, how many drinks per week?

12-34-56 or more
How many times do you eat out per week

Never12-34-56 or more
Do you take any supplements?

YesNo
If yes, please list below
Do you exercise?

YesNo
If yes, please list the type(s) of exercise, how long you exercise and how many days per week.
Please List Potential Obstacles

NoneTimeBudgetCommitmentSpouse/PartnerOther
How long have you been thinking about achieving your goals?

1 month3 months6 months1 year or more
On a scale of 1 to 10, how serious are you about accomplishing your goals with 1 being not serious and 10 being very serious.

1

2

3

4

5

6

7

8

9

10

1 is Not serious, 10 is Very Serious
Are you the primary decision maker in your household?

YesNo
How will accomplishing your health goals change your life?
Should be Empty:

Intake Form

Areas of Concern