Intake Form

Intake Form

Congratulations on taking this step. My intention is to serve you in a timely and professional manner, taking into account everything that potentially plays a role in what you're seeking help for. The purpose of this form is to gather the relevant details of your circumstances. This information will be placed in your personal file and kept strictly confidential. It will only be seen by me, your practitioner. It will not be seen by any other individual, company, or agency without your consent and explicit request. Please complete this form at least 48 hours in advance of your initial consultation, and send by email any relevant medical tests and records.Please commit to the following: I will complete this questionnaire myself and truthfully. I understand that withholding or misrepresenting medical information could result in serious health complications.
Full Name

First NameLast Name
Email Address
example@example.com
Mobile Phone Number

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Birth

Hour Minutes

AM/PM Option
Place of Birth
Gender

Other
Sexual Orientation
Height
Weight
Blood Pressure
Relationship Status (e.g., single, partnered, married, divorced, widowed, other)
Ages of children and parenting status (e.g., single parenting, co-parenting)
Faith Affiliation
Education (discipline & degree)
Occupation
Current concerns and your reason for seeking help

For medical conditions, please include the following details (from the most recent to the oldest):

Rows	name of condition	when it started	how often it bothers you	severity (1 - 10)	treatments & outcomes
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Have you ever had any of the following?

Other
Surgeries and Hospitalizations (for pregnancies / miscarriages, include dates)?
Exercise Habits
Exercise (regular indoor / outdoor activities). Include duration and frequency.
Current diet / eating style

List your medications, vitamins, supplements, herbal remedies, immunizations (recent/annual). Where relevant, include the following details:

Rows	item	dosage & frequency	reason for use	benefits experienced	adverse reactions
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Allergies (include details)

What is your average daily/weekly consumption of the following (include relevant details):

Rows	amount
Water
Fruit juice (natural or other)
Coffee (caffeinated / decaffeinated?)
Tea (caffeinated / decaffeinated?)
Sodas
Red meat
Poultry
Dairy products
Refined sugar (chocolate, candy, etc)

Alcohol Use
Alcohol (include years of use, frequency, and amounts):
Do you currently smoke?
Cigarettes / cigars / chewing tobacco (include years of use, frequency, and amounts):
Other substances (item, years of use, frequency, and amount):
How soon would you like an appointment?
What is your typical availability (days and times, including weekends)?
Payment Option
Would you like to receive our e-newsletter?
Consent & Confidentiality
Should be Empty: