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Client Intake Form
What’s your first name?
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What’s your last name?
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Street Address
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Postal / Zip code
Street Address Line 2
Region/State/Province
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Health + Medical History
Height
Current Weight
Ideal Weight
Birthday
Gender
Referred by:
Personal Health History
Please include your Diagnosis, Date of Onset, Current or Past + Description
Please include your Family Member + Illness(es)
Please include your Hospitalization/Surgeries, Date + Reason(s)
Please list any allergies or sensitivities that you have (food, environmental, etc.) + your Reactions
Were you born vaginally or via C-section?
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vaginal
C-section
I'm not sure
Were you breast-fed or formula-fed?
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Breastfed
Formula
A mix of both
I'm not sure
Females: Where are you at with your menstrual cycle?
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Cycling (regular)
Cycling (irregular)
Currently on Birth Control
Perimenopausal
Menopause
Post-Menopausal
Other
Have you ever taken birth control?
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No
Yes
Have you ever taken antibiotics?
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No
Yes
Have you ever been on hormone replacement therapy?
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No
Yes
Have you ever had Breast Implants?
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No
Yes
Supplements/vitamins
List all the supplements you're currently taking including vitamins, herbs, minerals. Please include the Brand Name, Dose + Frequency, Start Date + Reason for taking it
Medications
List all medications you're currently taking. Please include Brand Name, Dose + Frequency, Start Date + Reason for taking.
Ranking current health concerns
List your current health concerns from most important/worst and rank from 5 (most intense) to 0 (not intense). Please include how often it bothers you + how long it has been present for.
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