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?
I accept terms & conditions
I accept terms & conditions
Thank You! Please take some time to explain your health history. List any significant illnesses, surgeries or procedures and life events, including dates. No detail is insignificant.
Please take a current picture of each of the following:
Please tell me a little about your daily rhythms. Check all that apply:
Please describe your exercise regimen on any given week:
Tell me a little bit about your diet. What kind of things do you typically eat for breakfast, lunch and dinner? Generally when do you eat? Do you follow any guidelines, i.e. gluten-free or vegan, do you practice intermittent fasting, etc?
When do you eat your largest meal? How often do you eat out? Please list any food allergies or sensitivities:
Please tell me a little about your digestion. Check all that apply:
What is the most common theme or aggravator?
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 describe anything else you think is important about your elimination. Thank you!
Please tell me a little about your sleep. Check all that apply:
The chest, heart and lungs:
Describe your cycle here:
Please address anything else relevant about your reproductive/female health:
Please address anything else relevant about your reproductive/male health:
Mental and emotional condition:
Submit