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Client Intake Form

Welcome! We look forward to helping you reach your goals. Please fill out the form below so we can get you set up for success.

PERSONAL INFORMATION

Full Name

Email

Phone

Address

Date of Birth

Height

Your Occupation

Employer

Spouse's Occupation

Who can we thank for referring you to our office? (Please be as specific as possible)

MEDICAL HISTORY

Please list any surgeries you've had:

What medications, supplements, or herbs are you taking?

Any allergies? If so, what?

Are you pregnant?

Are you pregnant?
A
B

Are you currently breastfeeding?

Are you currently breastfeeding?
A
B

How many children do you have, if any?

WEIGHT HISTORY

How long have you been overweight?

Have you tried to lose weight in the past? How?

What are your top two reasons you would like to lose weight?

Has your doctor recommended you lose weight?

Has your doctor recommended you lose weight?
A
B

Can you attribute the weight gain to anything?

GOALS

What is your goal weight?

When were you last at that weight?

On a scale of 1-10, with 10 meaning "I am fully committed, I want to start now," and 1 meaning, "not interested," what is your current commitment level?

On a scale of 1-10, with 10 meaning "I am fully committed, I want to start now," and 1 meaning, "not interested," what is your current commitment level?

HEALTH HISTORY

List your current health concerns in order of importance

How does the greatest health concern limit you the most?

How committed are you towards making valuable changes?

How committed are you towards making valuable changes?
A
B
C

Did you have the following disease, get immunized, or neither?

Had the Disease
Got Immunized
Neither
Shingles
Covid
Boosters
Flu

If you are/were a smoker, for how many years?

If you drink/drank coffee, how many oz. per day?

If you drink/drank soda, how many oz. per day?

If you drink/drank alcohol, how much and how often?

Fatigue Level

Fatigue Level

If you have fatigue, when is it the worst?

Stress Level

Stress Level

Potential cause of stress

Energy Level

Energy Level

Do you exercise? If so, what type and how often?

SKIN: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Skin: Rash / Hives
Skin: Psoriasis / Eczema
Skin: Itchy / Dry

NOSE: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Nose: Frequent Colds
Nose: Congestion
Nose: Seasonal Allergies

NECK / BACK: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Neck/Back: Pain in Neck
Neck/Back: Mid Back Pain
Neck/Back: Low Back Pain

CARDIOVASCULAR: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Cardiovascular: High Blood Pressure
Cardiovascular: Low Blood Pressure
Cardiovascular: Edema
Cardiovascular: Palpitations
Cardiovascular: Heart Attack
Cardiovascular: Stroke
Cardiovascular: High Cholesterol

GASTROINTESTINAL: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Gastrointestinal: Heartburn
Gastrointestinal: Indigestion
Gastrointestinal: Bloating
Gastrointestinal: Nausea
Gastrointestinal: Change in Appetite
Gastrointestinal: Diarrhea/Constipation

MUSCULOSKELETAL: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Musculoskeletal: Arthritis
Musculoskeletal: Leg Cramps
Musculoskeletal: Joint Pain

MENTAL / EMOTIONAL: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Mental/Emotional: Depression
Mental/Emotional: Anxiety
Mental/Emotional: Eating Disorder

OTHER: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Other: Headache
Other: Hypoglycemia
Other: Diabetes
Other: Thyroid Disease
Other: Cancer
Other: Gallbladder Disease
Other: Kidney Disease
Other: Gout

SLEEP: Please select "Yes" if you have the problem now, "No" if you've never had the problem, or "Past" if you had the problem in the past:

Yes
No
Past
Sleep: Must nap during the day
Sleep: Sleep apnea

Do you have daily bowel movements?

Do you have daily bowel movements?
A
B

How long do you sleep per night?

If you wake up frequently, what is the reason?

If you have sleep apnea, do you use a CPAP machine?

If you have sleep apnea, do you use a CPAP machine?
A
B

TOXIN EXPOSURE

Did you grow up near any refinery, polluted area or in a home with lead paint?

Did you grow up near any refinery, polluted area or in a home with lead paint?
A
B

Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials?

Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials?
A
B

Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing?

Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing?
A
B

Are you particularly sensitive to perfumes, gasoline, or other vapors?

Are you particularly sensitive to perfumes, gasoline, or other vapors?
A
B

Do you use pesticides, herbicides, or other chemicals around your home?

Do you use pesticides, herbicides, or other chemicals around your home?
A
B

Please list any additional information/topics which you believe is important: