INTAKE/HISTORY FORM
Date_______ Date of Birth_______________
Name_______________________________________________
Address_____________________________________________
____________________________________________________
Phone _____________________ Cell_____________________
Email________________________________________________
Reason/s for consult
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have previous experience with herbs_______natural supplements________ acupuncture/bodywork___________
Diet
Typical Breakfast
Typical Lunch
Typical Dinner
Desserts and/or snacks
Favorite foods or cravings
Beverages
Body weight in pounds______Water consumed in ounces per day.
Sleep Pattern
_____fall asleep easily______can’t fall asleep
Wake______times per night_______what time
How do you feel in the AM?_____________________________
Do you feel rested and energetic for your day?________________________
Bowels
Moves
_____daily_____every 2-3 days_______less often difficult_______ easy________
loose__________hard_________ complete______incomplete_______
do you take probiotics________ How much?__________
Mood/Emotions
Currently____________________________________________________________________________________________
Past issues__________________________________________________________________________________________
Libido _____absent _____low_______average______good
Work
_____satisfying______unsatisfying_______retired ________unemployed
_______work too hard ________work a reasonable amount of hrs _____avg. per week
Hobbies or favorite acitivities
_____________________________________________________________________________________________________
Exercise
_______intense________average________infrequent________not at all
_______frequency________type of activity__________level of enjoyment
Energy Level
____exhausted_______tired occasionally______up and down______good energy
Menses
______ Menopausal_________ Number of Preg_____Number of births_______
Birth Control_________ Discomfort________________
Medications
____________________________________________________________________________________________________
Surgeries
____________________________________________________________________________________________________________
Significant Medical History with dates,
Significant Mental/Emotional History with Dates.
Childhood issues and illnesses.
Relationship to family of origin.
Current network of support
Any other information that would be useful to share.
Date_______ Date of Birth_______________
Name_______________________________________________
Address_____________________________________________
____________________________________________________
Phone _____________________ Cell_____________________
Email________________________________________________
Reason/s for consult
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have previous experience with herbs_______natural supplements________ acupuncture/bodywork___________
Diet
Typical Breakfast
Typical Lunch
Typical Dinner
Desserts and/or snacks
Favorite foods or cravings
Beverages
Body weight in pounds______Water consumed in ounces per day.
Sleep Pattern
_____fall asleep easily______can’t fall asleep
Wake______times per night_______what time
How do you feel in the AM?_____________________________
Do you feel rested and energetic for your day?________________________
Bowels
Moves
_____daily_____every 2-3 days_______less often difficult_______ easy________
loose__________hard_________ complete______incomplete_______
do you take probiotics________ How much?__________
Mood/Emotions
Currently____________________________________________________________________________________________
Past issues__________________________________________________________________________________________
Libido _____absent _____low_______average______good
Work
_____satisfying______unsatisfying_______retired ________unemployed
_______work too hard ________work a reasonable amount of hrs _____avg. per week
Hobbies or favorite acitivities
_____________________________________________________________________________________________________
Exercise
_______intense________average________infrequent________not at all
_______frequency________type of activity__________level of enjoyment
Energy Level
____exhausted_______tired occasionally______up and down______good energy
Menses
______ Menopausal_________ Number of Preg_____Number of births_______
Birth Control_________ Discomfort________________
Medications
____________________________________________________________________________________________________
Surgeries
____________________________________________________________________________________________________________
Significant Medical History with dates,
Significant Mental/Emotional History with Dates.
Childhood issues and illnesses.
Relationship to family of origin.
Current network of support
Any other information that would be useful to share.