Client Health Intake Form

Contact Information

Full Name *

Email *

Phone Number *

Time Zone

Today's Date *

Street Address

City

State

Zip

Personal Information

Date of Birth

Occupation

Height

Weight

Emergency Contact Name & Phone

Health Goals

Goal 1

Goal 2

Goal 3

Health History

Describe your current health concerns / symptoms:

What treatments or therapies have you tried? Did anything help?

Have you lived or traveled outside the United States?

Yes No

Have you taken oral steroids?

Yes No

Have you had any recent major life changes or stressors?

Yes No

Do you have food sensitivities or allergies?

Yes No

How often do you take antibiotics?

List vitamins, minerals, medications, or supplements you currently take:

Diet & Digestive Health

Breakfast:

Lunch:

Dinner:

Snacks / Drinks:

Do you experience symptoms after eating?

Belching Bloating Gas Pain Reflux

If yes, when?

Immediately 1–2 Hours Later Other

How many bowel movements per day?

Do you drink alcohol?

No Occasionally Weekly Daily

Water intake per day:

Environmental Exposures

Mercury amalgam fillings?

Yes No

Exposed to toxic metals?

Yes No

Exposure to mold?

Yes No

Use scented candles / air fresheners / chemical cleaners often?

Yes No

Stress & Lifestyle

Stress level (1–10):

Exercise regularly?

Yes No

Sleep issues:

Trouble falling asleep Staying asleep Wake tired Interrupted

Average hours of sleep:

Women's Health (if applicable)

Do you have a menstrual cycle?

Yes No

Is it regular?

Menopausal status:

Pre Peri Post-Menopausal

Symptoms:

PMS Mood Changes Heavy Flow Cramps Irregular Cycle

Additional Health Concerns

Weight loss / gain / maintaining issues?

Headaches or migraines? How often?

Thyroid dysfunction?

Yes No

Anxiety / Depression / Seasonal Depression?

Yes No

Skin issues?

Dry Acne Eczema Flaky Rashes

Other concerns:

Contact Information

Personal Information

Health Goals

Health History

Diet & Digestive Health

Environmental Exposures

Stress & Lifestyle

Women's Health (if applicable)

Additional Health Concerns

Consent