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Client Intake Form
What’s your first name?
What’s your email address?
What’s your last name?
What’s your phone number?
Postal / Zip code
Street Address Line 2
Health + Medical History
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?
I'm not sure
Were you breast-fed or formula-fed?
A mix of both
I'm not sure
Females: Where are you at with your menstrual cycle?
Currently on Birth Control
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?
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
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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