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New Client Confidential Intake Forms
Protocols & Conditions
Informed Consent/Client Declaration
First name
*
Last name
*
Birthday
*
Month
Day
Year
Height
Weight
Street Address
*
City, State, Zip Code
*
Mobile Phone
*
Email
*
Emergency Contact/Relation
*
Phone
*
Relationship Status
Spouse/Partner Name
# of Children
Who can we thank for referring you?
Occupation
Do you enjoy your job?
Yes
No
What is the primary reason for your visit?
Have you sought help for this before?
Yes
No
What are your expectations after the sessions?
METABOLISM
Weight Gain
Weight Loss
High/Low BP
Blood Sugar
Thyroid
DIGESTIVE
Heartburn
Abdominal Pain
Gas/Bloating
Diarrhea
Constipation
Blood in Stool
Ulcers
Colitis
Liver Disease
DENTAL
Tooth Problems
Root Canals
Amalgam Fillings
Difficulty Chewing
TMJ
FEMALE
Pregnant
Problems w/Periods
Cancer
Breast Tenderness
Breast Implants
Menopausal Symptoms
SKIN
Rash
Dry Skin
Acne
Eczema
Botox
Injectables
CHEST
Chest Pain
Palpitations
Cough
Shortness of Breath
Asthma
URINARY
Frequent Urination
Difficult Urination
Incontinence
STRUCTURAL
Arthritis
Osteoporosis
Foot/Ankle Swelling
Blood Clots/Phlebitis
Varicose Veins
Recent Surgery
Neck Pain/Problems
Back Pain/Problems
Sciatica
EYES/EARS/MOUTH
Headaches
Dizziness
Ringing in Ears
Blurred Vision
Sinus Problems
Difficulty Swallowing
Mouth Sores
NEUROLOGICAL
Numbness or Tingling
Weakness
Insomnia
Poor Balance
ALLERGIES
Medications
Chemicals
Food
Plants
IMMUNE
Chronic Fatigue
Fibromyalgia
Yeast Infections
Viral Infections
Strep or Mono
Epstein-Barr
Lyme
Medications, Herbs, Supplements (List name, dose & purpose)
We recommend drinking 90-128oz. of water daily starting on the day before your first session and for the days of integration. Do you expect any difficulty with this?
YES
NO
Do you use any of the following?
Alcohol
Coffee/Tea
Tobacco
Drugs/Cannabis
List any injuries/accidents
Toxic Exposure
Traumatic life events leading to illness
Any other medical conditions to be aware of?
Cancer
Heart Problems
Stroke
Seizures
Diabetes
MS
Other
Family Medical History
Diabetes
Heart Problems
High BP
Cancer
Alzheimer's
Areas in body of complaint or tension
Surgeries (list any metal plates/rods/screws)
CURRENT PAIN LEVEL (1=very low, 5=very high)
CURRENT STRESS LEVEL (1=very low, 5=very high)
CURRENT ENERGY LEVEL (1=very low, 5=very high)
Submit
Online New Client Fillable Form
(takes approx 10 min.)
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