Christine Garcia
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Client Intake Form

Name: _________________________________ Date of Birth: __________________ Male/Female

Height: __________ Weight: __________ Marital Status: _________________

Number of Children: ______________ Ages: _______________

Address: _____________________________________________________________________________________

 

Do you have any health concerns? ______________________________________________________________

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If yes, do you experience any symptoms? ________________________________________________________

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What would you like to accomplish with this visit? _________________________________________________

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Please list any pertinent family medical history.____________________________________________________

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List any major illnesses or surgeries. _______________________________________________________________

Are you taking any medications? If yes, please list ___________________________________________________

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Are you currently taking supplements, vitamins, or herbal products? Please list. _________________________

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Do you currently have any dietary restrictions? _______________________________________________________

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How many meals a day do you eat? ___________ How much water do you drink a day? ___________________

Please describe your favorite foods __________________________________________________________________

How many bowel movements a day do you have? _____________

Do you have any addictions? ______________________ Do you have restful sleep? _________________________

Please describe your energy level ____________________________________________________________________

Do you consume energy drinks? _______________ If yes, how many per day? ______________________________

What would you describe as your dominant emotions? __________________________________________________

Describe your living situation. _________________________________________________________________________

What type of work do you do? _________________________________________________________________________

Have you experienced any major changes in the past year? _______________________________________________

Is there anything I have not covered that you feel I should know? __________________________________________

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If you have any questions about this form, contact me at 252-599-2687. I look forward to building a relationship with you.

 

 

 

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