Wildflower Clinic Client Intake Form
www.wildflowerclinic.com
Client Personal Information:
Please fill out the following fields:
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
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1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Birth Time (Ex: 9:49 AM)
*
Blood Type (A, B, AB, or O)
*
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Next
Client Emergency Contact:
Please fill out the following fields:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
Relationship
*
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Client Health Intake Questions:
Please answer these questions as honestly as possible.
Please list any diagnosed medical conditions and the year they were diagnosed:
*
Please list any prescribed pharmaceutical medication you are currently taking and the dosage:
*
Please list any medications you have taken in the past:
*
Please list any medical family history:
*
Were you a C-section baby?
*
YES
NO
Are you currently taking a form of birth control? If yes, what brand/ IUD and for how long?
*
How many servings of dairy do you consume daily?
*
0
1-2
3-4
5+
How many servings of gluten do you consumer daily?
*
0
1-2
3-4
5+
Please choose the diet that best reflects your eating routine:
*
Keto
Paleo
Processed foods, red meat, sugar, and high carbohydrates
Vegan
Vegetarian
I do not adhere to any diet
Whole foods, unprocessed, low sugar, high fat
None of these fit my diet preferences
Other
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How frequently do you exercise/ move the body (weekly)?
*
0 days
1-2 days
3 days
4-5 days
Everyday
How many bowel movements do you have daily?
*
3
2
1
I do not have a daily bowel movement, it is more infrequent
What do your bowel movements look like? (check all that apply):
*
Liquid
Small sectioned pellets
Thick solid snake shape
Hard sections
None of the forms listed
Do you currently experience any of the following symptoms when passing a bowel movement?:
*
Straining
Constipation
Bleeding
External Hemorrhoids
Stomach Pain
Pelvic Pain
Stomach Cramping
Excessive Gas
None of the listed issues
Other
Do you smoke cigarettes and/or marijuana?
*
YES
NO
If yes, how many times a week?
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Please check any illness, disease, or condition that applies to you.
*
Allergies
Arthritis
Anxiety
Autoimmune flare
Celiac Disease
Crohn's Disease
Depression
Diabetes
Eczema
Emotional Blockages
Fatigue
Heart Disease
EBV Infection
Hemmorrhoids
High Blood Pressure/Cholesterol
H-Pylori Infection
Hypersensitivity flare
Hormonal Imbalance
Hyperthyroidism
Hypothyroidism
IBS
Insomnia
Genital Issues
Lyme Disease
Migraines
Mood Swings
Panic Attacks
Psoriasis
Rashes/ Pimples
PTSD
SIBO
Sleep Dysfunction
Sexual Dysfunction
Stress
Tension Headaches
Ulcerative Colitis
None listed
Other
What are your specific health concerns that you are coming to the Wildflower Clinic for?
*
Do you currently or have you ever had cancer?
*
YES
NO
I am in remission
Are you currently pregnant?
*
YES
NO
I am trying to conceive
Please describe any traumatic events that have taken place in your life: (emotional, physical, spiritual etc.) *Feel free to write "skip" if this question is in any way triggering or if you don't feel comfortable sharing this information.
*
Are you ready to make significant health changes in order to see results in your current state of health?
*
Yes, I am ready to make necessary changes to my health routine with the guidance and resources from the Wildflower Clinic
Yes, but gradually, I understand this will affect the results of my progression
I am considering implementing the necessary changes to see results
I am not ready to make any changes to my routine at this stage
How did you hear about the wildflower clinic?
*
Referral From Current Wildflower Clinic Client
Google search
Instagram
Facebook
Flyer or Business Card
Other
What is your sun sign? (birth sign: example: May 16th = Taurus)
*
What is your rising sign? (Ascendant astrological sign)
*
Please list your dental history: (Ex: Amount of Cavities, Root Canals/ Crowns/ Bleeding Gums)
*
If referral, what client referred you here? :)
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