Client Intake Form Client Information Your Name Birthday Age Height Weight Desired Weight Goal (If Applicable) When's the last time you remember feeling really great? Finish this sentence for me: "I haven't felt great since…” What are your primary concerns? These concerns can be physical, emotional, and spiritual. Symptoms Describe your symptoms and their location Describe your symptoms on a good day Typical Day Worst Day What makes it better or worse? Have you seen a Naturopathic Doctor or Holistic Nutritionist for this symptom, if so what was the treatment and did it work? What was going on in your life when the symptoms began? Have you had Intolerance Testing? If so, please list allergens and intolerances How much water do you drink daily? Do you have Amalgam fillings? If so, how many? How long have you had them? Have you received vaccinations? How Many? How Long Ago? How many antibiotics have you used in the last year? Last 5 years? Lifetime? List major surgeries and years it was performed Any missing body parts or organs? Any major past trauma to the body? Any major shift in life circumstances within the last 5 years? List of current medications List of supplements if taking any Happiness Waking energy level Evening Energy Level Personal happiness level Work Family & relationships Sleep Total hours of sleep? Total hours of uninterrupted sleep? If you have disturbed sleep, what is the time of the disruption? Do you dream? YesNo Do you remember your dreams? YesNo How long does it take to fall asleep? Do you wake refreshed? YesNo Digestion What is your average number of bowel movements per day? Do you have any days without a BM each week? YesNo Do you have a BM within 2 hours of waking up? YesNo Are your BMs complete? YesNo Well formed? YesNo Any blood? YesNo Any mucus? YesNo *MARK ALL THAT APPLY Dark circles under the eyesAcneEczemaHistory of asthma/sinusitisSore throat/stiff neckHistory of herniasHistory of acid refluxHistory of migrainesHistory of ear itching/infectionsFatigue 2+ hours after eatingItchy eyesNosebleedsHistory of irritable or inflammatory bowel Myofascial / Neurological *MARK ALL THAT APPLY Back painShoulder painNeck painSciaticaCarpal tunnel syndromeTMJ syndromeNumbness/tinglingSeizuresMuscle pain that moves from place to place Male Reproductive *MARK ALL THAT APPLY Diminished urinary streamDifficulty achieving erectionDifficulty maintaining erection Are you on Hormones or hormone replacement therapy? YesNo Female Reproductive Menstrual cycle is: Regular (4-6 days)LongShort Menstrual flow is: RegularHeavyLight Are you on Hormones or hormone replacement therapy? YesNo Acidity & Nutrient Deficiencies *MARK ALL THAT APPLY Red eyesSensitive skinHyperthyroidismHypothyroidismBrittle nails/hairMultiple broken bonesClear urineArthritisEasy bruisingSlow reflexes/recallCavitiesHigh blood pressureLow blood pressureHeart palpitationsKidney stonesHigh cholesterol Digestive *MARK ALL THAT APPLY ConstipationDiarrheaAlternating diarrhea & constipationNauseaVomitingEasy dizzinessAcid refluxHemorrhoidsHerniasFlatulenceRectal bleedingRectal itchingHistory of ulcersMucus in stoolsUndigested food in stoolsClay colored stools Emotion Check all that apply Fire: Unworthy/resistant to change/accepting of defeatEarth: Busy as escape/excessive concentration/mental chatter/easily overwhelmedGold: Grieving/keeping it inside/can’t let goWater: Lack of trust/afraid/worried/anxiousWood: Angry/indecisive/frustrated/impatient/complaining/timidAccessory Fire: Alone/isolated/neglected/guilt/excessive thought/second guessing self Please leave this field empty. Your email
