Client Intake Form

Please fill out the following form to the best of your knowledge to help me understand the condition of your health.

Are you currently diagnosed with a medical condition or injury?
Are you currently working with any type of healing or medical practitioner?
Please take a current picture of each of the following:
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Please tell me a little about your daily rhythms. Check all that apply:
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Please tell me a little about your digestion. Check all that apply:
Please tell me a little about your elimination. Check all that apply:
Please tell me a little about your stools. Check all that apply:
Please tell me a little about your sleep. Check all that apply:
The head:
The neck:
The eyes:
The ears:
The nose:
The mouth
The chest, heart and lungs:
The abdomen:
Skeleto-muscular system:
Nervous system:
Circulatory system:
Integumentary system:
The female body:
The male body:
Mental and emotional condition: