Intake Form

Intake Form
Please fill out all questions to the best of your ability. If a question is not relevant to you, please indicate that in the answer field.
Name of person seeking care

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender of person seeking care
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation (or grade level/education level if a student)
If you are filling the form out for someone else - please provide your name.

First NameLast Name
What is your relationship to the person seeking care?
Are you interested in a particular service?

Neurofeedback/BiofeedbackMetabolic Support & OptimizationPeak Performance TrainingPersonalized Health Planning (multiple services)

What's Going On?
What the primary reason you're applying for care? What would you like to see improved or changed? How long has it been negatively impacting your life?
How severely is this impacting your daily life?

1

2

3

4

5

1 is Only a little, 5 is Extreme
What other approaches you have tried for this condition or symptoms: (Medication, behavior therapy, counseling, alternative medicine, etc.?) What was the impact? Did it last?

History & Habits
Are there any medical diagnoses being treated with therapies or medications currently? Please list all diagnosis and current prescription medications (including dosages).
Are you taking any over-the-counter medication or natural supplements? Please list and include dosages.
List surgeries or procedures for which you were under anesthesia - include the age you were during these procedures. Please include any complications of surgery or reactions to anesthesia.
Have you had any head injuries including concussions, traumatic brain injury, or medical issues/illnesses that resulted in neurological impairment.
List any significant illnesses and the age at which it was contracted (particularly any with high fevers).
Do you have any chronic symptoms or illnesses - when did they begin?
Have you experiences any recent significant changes in lifestyle have you experienced (job changes, age related changes, relationships, losses, etc)
List any allergies you have, the reaction you have to the allergen, and any medications you take for allergies. (Include environmental and pharmacological.)
Tell me a little about your food preferences - favorite foods, comfort foods, foods you can't eat and why, typical eating patterns and times, difficulties you may have with food (impulse eating, late night cravings, unintentional fasting, etc).
What are your favorite ways to move your body or exercise and how often do you do them? If you pursue any high levels of training in a sport(s), please provide details of your level and intensity of training.

Intake Form

What's Going On?

History & Habits

Questions & Intentions