top of page

Client Intake Form

Health + Medical History

Personal Health History
Were you born vaginally or via C-section?
Were you breast-fed or formula-fed?
Females: Where are you at with your menstrual cycle?
Have you ever taken birth control?
Have you ever taken antibiotics?
Have you ever been on hormone replacement therapy?
Have you ever had Breast Implants?



Ranking current health concerns

bottom of page