Amapola Healthy Living LLC
CLIENT INTAKE FORM
Date Today
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Month
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Day
Year
Date
Patient Information
Name
First Name
Last Name
Age
Date of Birth
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Month
-
Day
Year
Date
Gender
Female
Male
Non-binary
Transgender
Prefer not to say
Other
Pronouns
She/Her
He/Him
They/Them
Prefer not to say
Other
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Health Information
Date of Last Physical Exam
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Month
-
Day
Year
Date
Current Medical Conditions (select all that apply)
Cardiovascular Disease
Digestive Disorder (IBS etc)
Metabolic Disorder
Respiratory Disease
Liver Disease
Kidney Disease
Osteoporosis
Chronic Pain
Mental health Concerns (anxiety etc)
Dementia
Alzheimer's disease
Endometriosis
Neurological Disease
Cancer
Thyroid Disease (hypothyroidetc)
Blood Disorder
Skin Conditions (eczema etc)
Sensitivities (foods etc)
Overweight
Obesity
Underweight
PCOS
Other
Current Medications (if any):
Allergies (if any):
Do you have a family history of health conditions that we should consider indeveloping your nutritional plan?
This could include chronic conditions like heart disease, diabetes, cancer, genetic disorders among yourimmediate family members (parents, siblings, and children), or even your grandparents. Information aboutyour family's health history can help us understand potential genetic predispositions and better personalizeyour nutritional recommendations. If there's a pattern of specific diseases or conditions in your family, pleaseprovide as much detail as possible.
EMOTIONAL WELLNESS
How would you rate your overall emotional health
Please Select
Poor
Fair
Good
Excellent
Mental Health
Anxiety
Depression
Low Mood
Seasonal Affective Disorder(SAD)
Anorexia Nervosa
Bipolar
Schizophrenia
Eating Disorders
Bulimia Nervosa
Binge-Eating
Other
None Apply
Please provide additional information and any medications you're currently taking.
WELLNESS GOALS AND OBJECTIVES
Personal Goals: What are your top three personal goals you wish to accomplish in the next year?
Challenges: What do you perceive as the biggest obstacles or challenges in your personal life currently?
Strengths: What would you consider your top three personal strengths?
Areas for Improvement: In which areas of your personal life do you feel you need improvement or change?
Personal Fulfillment: On a scale from 1 to 10, how fulfilled do you feel in your personal life? What elements do you feel wouldincrease this score?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
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