Intake Form
Share the details we need to get started.
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason/s for Consult
Do you have any previous experience with
Herbs
Natural Supplements
Acupuncture/Bodywork
Diet
Typical Breakfast
Typical Lunch
Typical Dinner
Desserts/Snacks /Favorite Foods/Cravings
Beverages/Caffeine/Alcohol
Body Weight
Water Drunk Ozs. Per Day
Sleep Pattern
Check One
Fall Asleep Easily
Can't Fall Asleep
Wakes How Many Times Per Night
Do You Feel Rested
Yes
No
How Do You Feel In AM
Digestion
Bowels Move per day
Select all that apply
daily
2-3 days or more
difficult
easy
loose
hard
feels incomplete
complete
probiotics
Exercise
Select
Intense
Average
Infrequent
Not at all
Frequency per Week
Type of Activity
Level of Enjoyment
Energy Level
Select
Exhausted
Tired Occasionally
Up and Down
Good Energy
Female Cycle
Select
Menses
Menopausal
Number of Pregnancies
Number of Births
Birth Control
Yes
No
Health History
Medications
Surgeries
Significant Medical History with Dates
Significant Emotional/Psych History with Dates
Childhood Issues and Illness
Relationship to Family of Origen
Current Network of Support
Mood and Emotions
Currently
Past Issues
Libido
Select
Absent
Average
Low
Good
Work
Select All That Apply
Satisfying
Unsatisfying
Retired
Unemployed
Work Too Hard
Work a Reasonable Amount
Hobbies
Describe
Any other useful or important information
Describe
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