CLIENT INTAKE FORM

Please fill out the below form and send at the bottom, or download and scan a completed pdf form here.

Name *
Name
Address *
Address
Statistics
HISTORY
4. How much time have you had to take off from work or school in the last year?
7. How have you dealt with these concerns in the past?
NUTRITIONAL STATUS
23. Which of the following foods do you consume regularly?
Are you currently on a special diet?
25. What percentage of your meals are home-cooked?
INTESTINAL STATUS
Bowel Movement Frequency
Bowel Movement Consistency
Bowel Movement Color
32. Please check any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
33. Please check frequency of the following:
Short term memory impairment
Shortened focus of attention and ability to concentrate
Coordination and balance problems
Problems with lack of inhibition
Poor organization abilities
Problems with time management (late or forget appts)
Mood instability
Difficulty understanding speech and word finding
Brain fog, brain fatigue
Lower effectiveness at work, home or school
Judgment problems like leaving the stove on, etc
HEALTH HAZARDS
ORAL HEALTH HISTORY
LIFESTYE HISTORY
SLEEP HISTORY
FOR WOMEN ONLY
SEXUAL HISTORY
MENTAL HEALTH STATUS
OTHER