Client intake form - Christine Garcia

Client Intake Form

Name: _______________________ Date of Birth: Male/Female

Height: Weight: Marital Status: _

Number of Children: Ages: _

Address: _____

　

Do you have any health concerns?

If yes, do you experience any symptoms?

What would you like to accomplish with this visit? _

_______________________

　

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. _

_________________________________________________________

　
Do you currently have any dietary restrictions? _

__________________________________________________________________

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.

　

　

　