Intake Interview Form & Assessment Questionnaire

Intake Interview Form & Assessment Questionnaire
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent to Treat:

1. I voluntarily give my consent for Exquisite Wellness Bar (EWB) to provide medical evaluation, care, and treatment as recommended by a licensed healthcare provider.

2. I understand that I am responsible for all costs associated with the services I receive at EWB.

3. I understand that I have the right to ask questions about my care and to discuss all recommended treatments with my healthcare provider.

4. I understand that I have the right to refuse any procedure or treatment at any time.

5. I acknowledge that no guarantees have been made regarding results or outcomes of treatment.
Signature

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Referred by:
Date of Birth

MonthDayYear
Date
Gender

MaleFemalePrefer not to say
Age
Height
Weight
Occupation
Blood Type (if known)
What are your top 3-5 health concerns?
What would you like to gain from working together? What are your personal health goals?

Rows	Never or NO	Monthly or YES	Weekly	Daily
Experience pain relief with aspirin
Crave fatty or greasy foods
Low or reduced-fat diet
Tension headaches at base of skull
Headaches when out in the hot sun
Sunburn easily or suffer sun poisoning
Muscles easily fatigued
Dry flaky skin or dandruff

Rows	Never or NO	Monthly or YES	Weekly	Daily
Awaken a few hours after falling asleep, hard to get back to sleep
Crave sweets
Binge or uncontrolled eating
Excessive appetite
Crave coffee or sugar in the afternoon
Sleepy in the afternoon
Fatigue that is relieved by eating
Headache if meals are skipped or delayed
Irritable before meals
Shaky if meals delayed
Family members with diabetes
Frequent thirst
Frequent urination