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Patient Health Intake Form

Date

Full name

Date of birth

Street address

City / State / ZIP

Phone

Email

Patient status

A
B
C
D

Student status

A
B
C

Occupation

Spouse / parent name (if applicable)

Spouse / parent occupation

Spouse / parent phone

EMERGENCY CONTACT

Contact name

Relationship

Address

Phone number

PERSONAL MEDICAL HISTORY

Please check any conditions you have now or have had in the past. Mark “none” if applicable.

Conditions

Other condition(s)

For checked conditions, note diagnosis, treatment and approximate year:

Prior surgeries/hospitalizations (procedure and year):

Current symptoms or main reason for visit:

SLEEP AND COMFORT

On which side can you sleep best?

Is there a position you cannot sleep in?

How long has your bed been in its present position?

Do you often have cold:

Do you often have hot:

Do you perspire excessively?

A
B

Are you sensitive to drafts?

A
B

Do you feel best in a hot, dry climate?

A
B

Do you feel best in a fresh, cool climate?

A
B

HEALTH BACKGROUND

Allergies (including medications, food, environmental)

Vaccinations

Dental work / dental history

DIET AND NUTRITION

Describe what you typically eat on an average day: Breakfast (foods/drinks and approximate time):

Lunch (foods/drinks and approximate time):

Dinner (foods/drinks and approximate time):

Snacks, desserts and beverages:

Which is your main/largest meal?

A
B
C
D

Do you eat protein in the morning?

A
B
C
D

If yes, which protein foods?

Dietary habits (How often do you eat:)

Daily
Weekly
Rarely
Never
Vegetables
Fruit
Meat/Fish
Eggs
Legumes

Dietary pattern:

A
B
C
D
E

Food restrictions/intolerances or foods avoided:

Water per day (cups/oz)

Caffeine (type/amount)

Sugary drinks/juice per day

Meals per day

Do you skip meals?

A
B

Any recent changes in appetite, weight or digestion?

MEDICATIONS AND SUPPLEMENTS

Check any medication categories you currently use:

Prescription medications (name and dose)

Vitamins / supplements (name and dose)

IMMEDIATE FAMILY HISTORY

Father: living? / age

Mother: living? / age

Siblings and ages

Check any conditions occurring in your immediate family:

For each checked condition, identify relative and age at diagnosis:

YOUR PERSPECTIVE

What do you believe is the cause of your current condition or health concerns?

ACKNOWLEDGMENT

I confirm that the information provided is accurate to the best of my knowledge. Patient signature:

Signature

Date

INFORMED CONSENT

I understand and acknowledge that the practitioner providing services to me is not a licensed medical doctor or physician and does not diagnose, treat, cure, or prevent diseases, prescribe medications, or provide medical advice.
I understand that the services, consultations, and information provided are intended solely for educational, informational, and general wellness purposes and are not intended to replace conventional medical care, diagnosis, or treatment by a licensed healthcare professional.
I acknowledge and agree to the following: Voluntary Participation: I am seeking holistic health and wellness information of my own free will and voluntarily choosing to participate in consultations and services offered by the practitioner.
Personal Responsibility: I understand that I am ultimately responsible for my own health, wellness decisions, and actions. I retain the right to accept or decline any educational information or wellness suggestions provided.
No Medical Diagnosis or Treatment: I understand that the practitioner does not diagnose medical conditions, prescribe medications, or provide medical treatment. Any discussion of nutrition, lifestyle, herbs, supplements, or other wellness approaches is for educational purposes only.
Medical Supervision: I understand that I should consult a licensed physician or qualified healthcare provider regarding medical concerns, symptoms, diagnoses, medications, and treatment decisions. I agree not to discontinue, modify, or replace prescribed medical treatments without consulting my prescribing healthcare professional.
By signing below, I acknowledge that I have read, understood, and voluntarily agree to the statements above


Client Name:

Client Signature:

Signature

Date: