Intake Release Form

Intake Form
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number

Area Code Phone Number
Cell Number *

Area Code Phone Number
Date of Birth *
Male female
Email
Emergency Contact - Phone *
How did you hear about us?
Please check ALL of the following symptoms, which you now have or have had in the past year. Be as thorough as possible! Your health history is strictly confidential.
General Syptoms *

Headache Fever Chills Sweats Fainting Allergies Dizziness Convulsions Loss of sleep Fatigue Nervousness Loss of weight Weight Gain
Numbness In...
Skin *

Skin eruptions Itching Bruises easily Dryness Boil Varicose Veins Sensitive Skin Hives or Allergies None
Urinary *

Frequent Urination Painful urination Blood in Urine Pus in urine Kidney trouble Inability to control Urine Prostate trouble None
Respiratory *

Chronic Cough Spitting up phlegm Spitting up Blood Chest pain Difficult Breathing None
Ear, Nose, Throat *

Earache Ear Noice Ear Discharge Nose Bleed Nasal obstruction Chronic sinus infection None
Cardio-Vascular *

Rapid heart beat Slow beating heart High Blood pressure Low blood pressure Pain over heart Heart attack Swelling of ankles Poor Circulation None
Brain *

Memory Loss Declining Focus Decrease in attention span Excessive brain fog Overly Stressed Short tempered Anxiety Depression Lack of motivation to accomplish goals Confusion None
Muscle, Bone & Joint *

Stiff neck Backache Swollen joints Painful tailbone Foot or ankle trouble Pain in: Shoulder, hips, legs, knees, feet or other None
Circle any of the following conditions you NOW have: *

Metal Filling Gum trouble Appendicitis Arteriosclerosis Arthritis Cancer Chicken Pox Diabetes Diphtheria Eczema Emphysema Epilepsy Fever Blister Colitis Goiter Gout Heart problems Malaria Measles Mental Disorder Flu Multiple sclerosis Nervous breakdown Pneumonia Polio Rheumatic Fever Mumps Stroke Small Pox Tuberculosis Ulcers Venereal Infection Whooping Cough Scarlet Fever Schizophrenia None
Please describe the what and when of any situation below:
Have you ever:
Constipation?
When did Constipation begin?
Have you ever been on birth control?
How many antibiotic treatments total in your lifetime?
What was the most recent medical situation or hospitalization (When/Where)?
Habits
Energy: Rate your energy level on a scale of 1-5 (5 being best) *
Energy: Where do you want your energy to be on a scale of 1-5 (5 beingthe best) *
Brain Fog: Rate your level of brain fog on a scale of 1-5 (5 being theworst) *
Attitude: Do you generally have a positive attitude? Yes/No *
Emotions: Do you have full control over your emotions? Yes/No *
Sleep: How many hours daily? *
What hours do you generally sleep *
Exercise: Do you exercise? *
Workout schedule *
Water: Do you drink ½ your body weight per day? *
What kind? *
Weight: Current weight - Ideal weight *
Do you eat organic? Yes/No If Yes, what foods *
Food: Too much? / Not enough? *
Do you eat processed foods? Yes/No - if yes how often? *
Do you eat gluten? Yes/No - if yes how often? *
Do you eat dairy? Yes/No – if yes how often? *
Do you eat fish? Yes/No – if yes how often? *
Do you drink alcohol? Yes/No - if yes how often? *
Do you drink coffee/tea? Yes/No – If yes how often? *
Do you smoke? Yes/No *
Do you take any vitamins or dietary supplements? Yes/No - If yes what do you take? *
List any medications (current or in the past year – please indicate) *
Do you take any over the counter drugs i.e. Aspirin, Advil, etc? Yes/No– if yes what do you take and how often? *
What is your primary health concern at this time? *
I certify to the best of my knowledge that the above information is accurate and that if anything changes in regards to my health I will notify someone from the Internal Harmony Team immediately.
E-Signature *

First Name Last Name
Date of Signature *
Should be Empty:

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Intake Form

Habits