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.