Holistic Health Intake Form
Date Today
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Month
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Day
Year
Date
Client Information
Name
First Name
Last Name
Age
Date of Birth
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Month
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Day
Year
Date
Gender
Male
Female
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
Civil Status
Please Select
Single
Married
Divorced
Widowed
Separated
Occupation
Emergency Contact Person
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Health Information
Health related questions
Yes
No
Remarks
Do you workout regularly?
Do you have any current diagnosed health conditions?
Do you smoke? If so, in what way & how often?
Have you been hospitalized due to injury?
Have you undergone any surgery?
Do you have any allergies?
Are you taking any medications right now?
What is Your Blood Type?
Please Select
O Negative
O Positive
A Negative
A Positive
B Negative
B Positive
AB Negative
AB Positive
NOT SURE
Do you feel any pain or discomfort in your body?
Yes
No
Where do you feel the pain? How strong (scale 1-10) and how often?
What part of the body?
How do you describe the pain?
Stabbing
Aching
Burning
Numbness
Pins & Needles
Other
Review of System
Normal
Not Normal
Notes/Remarks
Sensory (Eyes, ears, nose, throat)
Musculoskeletal (Mobility)
Integumentary (Rashes, irritation, pale)
Neurovascular (Paint, seizures, sensation)
Circulatory (Skin, edema)
Respiratory (Shortness of breath)
Dental (Dentures)
Psychosocial (Hallucinations, delusions)
Nutrition (Diet, weight change, swallowing)
Elimination (Constipation, incontinence)
Family History Illnesses
Asthma
Cardiovascular Disease
Diabetes Mellitus
Hypertension
Tuberculosis
Other
What is your current stress level?
Please Select
High-daily
Moderate-a few times per week/month
Low-Only when triggered by major life events
What are the main sources of stress?
Have herbal remedies or natural supplements been used before? If yes, which ones?
What kind of support or guidance is most desired from our Holistic wellness Services?
Fitness
Internal Health
Skincare
Psychological Guidance to aid in Mental Well-being
Other
Please share any other details in regards to formulating your best holistic health plan
Signature
Date Signed
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Month
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Day
Year
Date
Submit
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