Wellness IS
Client Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you give us permission to contact you via text, call, or email?
*
Yes
No
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Please select your gender at birth:
*
Male
Female
Other
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Height
*
Height in Feet-Inches (ex. 5'9")
Weight
*
Weight in pounds (lb)
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What is the primary concern(s) you wish to resolve?
*
When did it start? / How long have you been struggling with this?
*
Does it interfere with your ability to function in your daily life (work, down time, sleep)?
*
Please list any diagnostic markers (labs, bloodwork, MRI, Xray, etc.) interventions or diagnoses that you have received from a medical doctor or medical specialist.
If you have experienced any of the following, please indicate by clicking the box.
*
Broken a bone
Been hospitalized
Surgery
Endured an accident or trauma to the body
Please indicate if you are taking any of the medications below, by clicking the box.
*
Laxatives / stool softeners
Sedatives
Sleeping pills
Insulin
Blood thinners
Asprin
Vitamins
Herbs
Minerals
Blood pressure medication
Other
I do not take any medications or supplements
Please list any prescription medications, over-the-counter medications, vitamins, and/or supplements that you regularly take. Please include the specific name or brand (for products), the quantity you take, and how often you're taking them. If you are not taking anything, please write N/A in the box.
*
Please list any allergies or aversions. If none, please write N/A in the box.
*
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Vaccination Status (SARS Cov2-19 Covid)
*
I am vaccinated
I am not vaccinated
Which SARS Cov2-19 Covid Vaccine did you recieve?
*
Pfizer
Moderna
Johnson & Johnson
I was not vaccinated
Did you receive a SARS Cov2-19 Covid booster or boosters?
Yes, one
Yes, more than one
No
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Indicate your habit level with the substances below, by choosing none, light (yearly-monthly), moderate (weekly-daily), or heavy (daily-hourly).
Alcohol
*
Please Select
None
Light
Moderate
Heavy
Coffee
*
Please Select
None
Light
Moderate
Heavy
Tea
*
Please Select
None
Light
Moderate
Heavy
Soda
*
Please Select
None
Light
Moderate
Heavy
Diet Soda
*
Please Select
None
Light
Moderate
Heavy
Tobacco / Nicotine
*
Please Select
None
Light
Moderate
Heavy
Chips, cookies, processed snack foods
*
Please Select
None
Light
Moderate
Heavy
Sugar
*
Please Select
None
Light
Moderate
Heavy
Exercise
*
Please Select
None
Light
Moderate
Heavy
How often do you eat the following?
Fish
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Chicken / Turkey
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Pork
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Red Meat
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Dairy
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Dark Leafy Greens
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Fresh Fruit / Vegetables
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Packaged Foods
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Restaurant Meals
*
Please Select
Every meal
Once a day
Two times per week
Less than once per week
Never
Do you mostly eat organic meat?
*
Yes
No
I don't eat meat
How many bowel movements do you have per day?
Do you have a history of constipation?
Yes
No
No, but I have a history of diarrhea
What position do you primarily sleep in?
Please Select
Side
Back
Stomach
Which of the following best describes what you sleep on the majority of the time?
A mattress less than 10 years old
A mattress more than 10 years old
A waterbed
Couch / Recliner / Futon
Other
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Please list the issues and/or symptoms you are CURRENTLY EXPERIENCING & the frequency of the occurences.
Please list any symptoms and/or issues you experienced in the past, that you are NO LONGER EXPERIENCING.
What are top five emotions or feelings (positive or negative) that you experience on a regular basis? How do they impact your life?
Are there any specific feelings or emotions that you would like to work on experiencing more or less of?
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The following questions are to help us determine your natural body constitution (or Prakruti), according to Ayurvedic teachings.
Please click the description(s) that best describes you.
Rows
Thin
Moderate / Medium
Thick / Large
Body Frame
Rows
Low / Hard to Gain
Moderate
Overweight / Easy to Gain
Body Weight
Rows
Dry / Rough / Cool / Brown / Black
Soft / Oily / Warm / Fair / Red / Yellowish / White
Thick / Oily / Cool / Pale / Moist
Skin Qualities
Rows
Average
Thinning
Thick
Amount of Hair
Rows
Thin
Medium
Thick
Thickness of Hair
Rows
Black / Light Brown
Red / Early Grey / Blond
Dark Brown / Black
Color of Hair
Rows
Woolly / Dry
Soft / Oily
Wavy / Oily
Type of Hair
Rows
Brown / Black
Grey / Green
Blue
Color of Eye
Rows
Small
Medium
Large
Size of Eye
Rows
Dull
Sharp / Penetrating
Attractive
Description of Eyes
Rows
Protruded / Overly Small or Large / Gums Emaciated
Medium
Large
Teeth
Rows
Variable / Scanty / Irregular
Good / Excessive / Unbearable / Needs food
Slow, but steady / Easily skips meals
Appetite
Rows
Warm & Moist
Cold & Dry
Warm & Dry
Food & Drink Preference
Rows
Sweet / Salty / Sour
Sweet / Bitter / Astringent
Sour / Bitter
Taste Preference
Rows
Variable
Excessive
Scanty
Thirst
Rows
Quickly
Moderate
Slowly
How quickly do you eat?
Rows
Dry / Hard / Constipated
Soft / Oily / Loose
Thick / Oily / Heavy / Slow
Elimination
Rows
Very Active
Moderately Active
Lethargic
Physical Activity
Rows
Low
Moderate
High
Exercise Endurance
Rows
Low
Moderate
High
Exercise Tolerance
Rows
Quickly
Moderately
Slowly
Walk
Rows
Restless / Active
Aggressive / Intelligent
Warm & Dry
Mind
Rows
Generosity / Devoted / Adaptable
Perceptive / Courageous
Staple / Forgiving
Emotional Temperament
Rows
Change Quickly
Change Slowly
Unchanging
Moods
Rows
Excite Quickly
Anger Easily / Quick Temper
Slow to Get Irritated
Reaction to Stress
Rows
Aversion to Cold and Dry
Aversion to Hot and Moist
Aversion to Cold and Damp
Weather
Rows
Changeable
Fanatic
Steady
Faith
Rows
Good Short-Term Memory / Poor Long-Term Memory
Sharp / Good Overall
Slow to Learn but Rarely Forgets / Very Good Long-Term Memory
Memory
Rows
Fearful / Flying / Running / Jumping
Fiery / Anger / Violence / War
Romantic / Sexual / Watery
Dreams
Rows
Scanty / Interrupted
Medium Length / Sound
Heavy / Sound / Prolonged
Sleep
Rows
Fast
Sharp and Cutting
Slow / Monotonous
Speech
Rows
Poor / Spends Money Quickly on Trifles
Moderate / Spends on Luxuries
Rich / Money-Saver / Spends on Food and Necessities
Financial Status
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Is there anything else that you think we should know?
Submit
Should be Empty: