Personal Information

Name *

Today's Date *

Email *

Phone *

Street Address *

City, State, Zip *

Radio *

Female
Male
Other

Age *

Height *

Weight *

Are you presently on any medications (prescription or over the counter) or dietary supplements? Please list and include dosages. Attach additional sheet(s) if neccessary. *

N/A if nothing to list

Attachments

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

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How many cups of water do you drink per day? *

How many hours of sleep on average do you get each night? *

How often do you exercise? *

_______ hours per ________

What is your energy level like? *

No energy (0 1 2 3 4 5 6 7 8 9 10) High energy

How often do you eliminate your bowels? *

____/per day ____/per week

What is your stress level? *

No stress (0 1 2 3 4 5 6 7 8 9 10) High stress

How would you rate your overall health? *

Poor (0 1 2 3 4 5 6 7 8 9 10) Great

Which foods do you crave? Which foods do you dislike? *

List any serious illnesses or surgeries you have had in the past. *

N/A if none

Are you presently under a doctor’s care for any condition? (If yes, please describe and give dates of onset) *

N/A if none

What is/are your primary health concern(s) and what do you hope to achieve through this consultation? Please indicate when the main condition began. *

Name the two emotions you experience most often? (i.e.: Anger, irritability, sadness, worry, hopelessness, grief, fear, joy, happiness, other) *

Any additional comments which may or may not pertain to your present health. (Any odd symptoms, emotions, etc.)

How many people live in your household? *

Are you happy with your living arrangements? *

(If “No” please explain … optional)

What are some of your interests? *

What is your occupation? Do you like your job? Do you work with a lot of chemicals or pollutants? *

Have you ever been in an accident? *

(If yes, please explain)

Were there any major events which may have occurred in your life just prior to the onset of your primary condition? (i.e.: Birth, Death, Divorce, etc.) *

Family Medical History

Mother

Father

Siblings

Grandparents

Do you have any known allergies or sensitivities? *

Symptom Frequency/Severity Checklist

0. Never have the symptom

1. Rarely have the symptom

2. Occasionally have the symptom, effect not severe

3. Occasionally have the symptom, effect is severe

4. Frequently have it, effect is not severe

5. Frequently have symptom, effect is severe

Head

headaches

faintness

dizziness

insomnia

drowsiness

Other:

Eyes

watery or itchy

swollen, or sticky eyelids

dark circles under eyes

blurred vision

spots before eyes

poor vision

cataracts

glaucoma

Other:

Mouth and Throat

chronic coughing

frequently clearing throat

frequent sore throat

hoarseness

metallic taste

canker/cold sores

dry or itching mouth

grinding teeth

clicking jaw

Other:

Ears

itchy ears

earaches, ear infections

drainage from ear

ringing in ears, hearing loss

fullness of ears

poor hearing

Other:

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Client Intake & Health History Form

Please print and scan/email or post mail to me at least 7 days prior to your appointment, if possible.

Personal Information

Family Medical History

Please indicate whether you consume the following:

0 - Never

1 - Daily

2 - Weekly

3 - Monthly

Have you been diagnosed by a licensed physician with any of the following? Check all that apply.

Symptom Frequency/Severity Checklist

Head

Eyes

Mouth and Throat

Ears

Pu'erh Tea

Pu'erh Tea

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