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Deep-Rooted Clarity & Nourishment for Natural Healing
Get Started
New Client Intake Form
Please complete the following information. All of your information will remain confidential.
PERSONAL INFORMATION
Name
*
First Name
Last Name
Date
MM
DD
YYYY
Who referred you?
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best number to reach you:
(###)
###
####
Email
*
How young are you?
Date of Birth:
MM
DD
YYYY
Place of Birth:
Height:
Current Weight:
Weight 6 months ago:
Weight one year ago:
Would you like your weight to be different?
If so, what?
SOCIAL INFORMATION
Occupation:
Hours of work per week:
Hours spent commuting:
Do you like your job?
Past jobs:
Living situation – list peoples names and their relationship to you:
Pets:
Previous marriages?
Amicable?
HEALTH INFORMATION
What would you like to work on?
Please list your main health concerns or known imbalances:
Any other concerns and/or goals?
At what point in your life did you feel your best?
How is/was the health of your mother?
How is/was the health of your father?
Did you have a natural birth or were you born by cesarean section?
Were you breast fed as a baby?
What is your ancestry?
What is your blood type?
Pertinent family medical history:
(please select all that apply)
Alcoholism
Arthritis
Asthma
Breast Cancer
Depression / Anxiety
Diabetes
Epilepsy
Heart Disease
Mental Health
Obesity
Ovarian Cancer
Prostate Cancer
Thyroid
How is your sleep? (scale 1-10)
How many hours?
Do you experience insomnia?
Frequency?
Do you wake up at night?
What time?
If so, why?
Do you feel rested in the morning?
How is your vision?
How is your hearing?
Do you get frequent headaches or migraines?
Please describe the location and type of pain (stabbing, aching, vice grips, etc.):
Any pain, stiffness, or swelling?
Name any traumatic experiences in your life and when they happened? (Deaths, moving, divorce, seeing disturbing things, abuse):
How often do you move your bowels?
Describe form, color, texture:
Straining:
Yes
No
Sometimes
Constipation / Diarrhea / Gas?
Have you traveled Internationally lately? Where?
Do you experience acid reflux?
Any abdominal pain? Please explain:
WOMEN’S HEALTH
When was your first period?
Were your periods regular as a child?
Are your periods regular now?
How many days is your flow?
How frequent?
Painful history of periods?
Painful now?
Mood swings?
Clotting?
Low back pain?
Number of pregnancies:
Name(s) and age(s):
Cesarean or vaginal birth(s):
Describe each birth:
Abortions?
Miscarriages?
Date of last PAP smear?
Pads, tampons, sponge?
Birth control used past & present:
(please circle all that apply)
Birth control pill
Condoms
Cervical cap
IUD
Foam
Rhythm
Lenz
Do you experience yeast infections or urinary tract infections? Please explain:
Reached or approaching menopause? Please explain:
Are you sexually active?
Have you been tested for STI’s?
Aids?
Have you ever been abused sexually, mentally, physically, ritually?
By who?
For how long?
MEDICAL INFORMATION
Any serious illnesses/hospitalizations/injuries / surgeries?
(please circle all that apply)
Appendix
Implants
Tonsils
Wisdom teeth
Any additional information:
Childhood illnesses:
(please circle all that apply)
Acne
Bronchitis
Chicken pox
Diphtheria
German measles
Measles
Mumps
Pneumonia
Pertussis (whooping cough)
Polio
Rheumatic fever
Scarlet fever
Antibiotics? When / how often?
Do you take supplements, herbs or medications? Please list:
Do you smoke cigarettes or marijuana?
Yes
No
Past:
Yes
No
How many years?
Amount per day / week?
Do you drink alcohol?
Yes
No
On average how many units do you drink in one session?
On average, how many times per week do you drink alcohol?
How many times per month?
If you don’t drink alcohol how long ago was your last drink?
Do you self-medicate in other ways? Please explain:
Who is your primary care physician?
How often do you see them?
What is the date of last physical?
Allergies or sensitivities? Please explain:
Any healers, helpers, or therapies with which you are involved? Please list:
Do you exercise weekly?
Yes
No
Amount:
Frequency:
Weight bearing?
What is your energy like?
Are you part of a community? Please explain:
Do you enjoy spending time by yourself?
Social time?
Yes
No
How do you relax?
What do you like most about yourself?
Do you have a spiritual practice, have a belief in a Higher Power or Nature?
Do you pray or meditate?
Are family or relationship problems impacting on your life right now?
FOOD INFORMATION
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Do you drink with meals?
Yes
No
(please circle all that apply):
Coffee
Black Tea
Diet Soda
Green Tea
Herb Tea
Juice
Soda
How many glasses of water a day on average?
Past or present eating issues? Please explain:
Do you chew well?
Yes
No
Do you enjoy meals?
Yes
No
How do you feel physically after eating?
How many times a day, week, or month do you eat the following?
Kidney, black, pinto beans:
Red meat:
Fish:
Poultry:
Soy:
Dairy:
Eggs:
Mushrooms:
Seeds:
Nuts:
Soda:
Diet soda:
Honey:
Fruit:
Ice cream:
Sugar:
Artificial sweeteners:
Pasta:
Caffeine:
Herbal tea:
Fried food:
Rice, millet, barley, and other grains:
Salt to your food:
Vegetables:
Raw foods:
Seaweeds:
Miso:
Packaged / frozen food:
Baked goods:
Breads:
Snacks:
What oils do you cook with:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Do you cook?
Yes
No
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, caffeine, or have other cravings (salt, sweet, starch, fats, chocolate)?
Yes
No
Please list:
The most important thing I could do to improve my health is:
ADDITIONAL COMMENTS
Anything else you would like to share?
Thank you!
