Health Intake Form

Health Intake Form

Please complete this form before your first Wellness Session with Sonia Hayer.
Demographic Information
First Name*
Last Name*
Address*
City*
Province/State*
Postal Code/Zip*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date*

MonthDayYear
Date
Place of Birth
Height
Weight
Gender
Occupation
Referred By
Today's Date*

MonthDayYear
Date
Health Concerns
Describe Problem(s):*
What treatments have you tried?
Has anything been successful?
With whom do you live?
Do you have any pets or farm animals? If yes, where do they live?
Have you lived or traveled outside of your country? If so, when and where?
Have you or your family recently experienced any major life changes? If yes, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you lost from work or school in the past year?
Previous jobs
Did you feel safe growing up?
Have you been involved in abusive relationships in your life?
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
Do you feel safe, respected, and valued in your current relationship?
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues?
Medical & Surgical History
List past Medical and Surgical History
List previous hospitalizations
How often have you taken antibiotics?
How often have you taken oral steroids?
What medications are you taking now?
List all vitamins, minerals, and other nutritional supplements that you are taking now
Were you a full-term baby? A preemie? Breast-fed or bottle-fed?
As a child did you eat a lot of sugar and/or candy?
What is your typical daily diet
Tea (weekly amount)
Coffee (weekly amount)
Soda (weekly amount)
Other Caffeine (weekly amount)
Dairy (weekly amount)
Cheese (weekly amount)
Bread (weekly amount)
Sugar (weekly amount)
Candy/Chocolate (weekly amount)
Dessert (weekly amount)
Are you on a special diet?
Is there anything special about your diet that we should know?
Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with a particular food or supplement(s)?
Do you feel worse when you eat certain foods?
Does skipping a meal greatly affect your symptoms?
Have you ever had a food that you craved or really "binged" on over a period of time?
Do you have an aversion to certain foods? If yes, what foods?
How many bowel movements (BM) do you have per day?
Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?
Do you have intestinal gas? If so, when?
How many times per week do you drink alcohol?
Have you ever used recreational drugs?
Have you ever used tobacco? (If so, for how long?)
Are you exposed to secondhand smoke regularly?
Do you have mercury amalgam fillings in your teeth? If so, how many?
Do you have any artificial joints or implants? If so, which ones?
Do you feel worse at certain times of the year?
Have you, to your knowledge, been exposed to toxic metals in your job or at home?
Do odors affect you? If so, which ones?
How would you rate your current level of stress?
Have you ever had psychotherapy or counseling?
Are you currently, or have you ever been, married?
List your hobbies and leisure activities
Do you exercise regularly? If so, how many times a week?
What type of exercise is it?
Do your parents or siblings have (or had) any health issues? If so, please explain
Why do you believe you would be a good candidate to work with the practitioner?
Consent & Signature
Client Signature*

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Congratulations, you are on the path to taking your first step towards health and wellness!

* All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.

I have read and understand everything on this page. I acknowledge Sonia Hayer is natural health practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Stephen Cabral, his lab partners, his independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.

If you are under 18, pregnant or breastfeeding, or have liver or kidney disease, gallbladder conditions, appendicitis, an eating disorder, or type 1 diabetes you should consult with your primary healthcare practitioner before beginning detox. It’s also important that you check with your primary healthcare practitioner to see if you’re taking any medications that may be contraindicated with the ingredients.
Date*

MonthDayYear
Date
Should be Empty:

Health Intake Form

Demographic Information

Health Concerns

Medical & Surgical History

Consent & Signature