Client Intake/Assessment Form

Client Intake/Assessment Form

Please complete this form. This information will help us work together and help you

learn how to regain or maintain your health using natural options.

Date: ______

Client Intake Information:

Name: ______Sex: Female /Male

Address: ______

City: ______State: ______Zip: ______

Phone (Mobile): ______Phone (Home): ______

E-mail Address: ______

Occupation: ______Employer: ______

Age: _____ Date of Birth: ______Height: ______Weight: ______

Marital Status:

Single Single/in a Relationship Married Divorced Separated Widowed

Children Y/N #_____

Occupation/School: ______

Household Members:

Name Age Relationship

______

______

______

______

Primary Care Physician:

Name: ______

Address: ______

City: ______State: _____ Zip: ______Phone: ______

In Case of Emergency Please Notify:

Name: ______

Phone: ______Relationship: ______

Preferred Weekday and Time for Appointments: ______

How Did You Hear About Us?

Yellow Pages - Seminar - Brochure - Other

Referred by: ______

Personal History:

Please note approximately how many servings of the following you eat/drink in an

average week. Circle D for Daily or W for Weekly

-VegetablesD/WFruitsD/W Raw FoodsD/W

-Red MeatD/WChicken D/W FishD/W

-EggsD/WDairyD/W JuiceD/W

-White bread/rice/pasta D/WSoft DrinksD/W Restaurant Meals D/W

-Whole GrainsD/WOrganic FoodsD/W Nuts/SeedsD/W

-Cold Breakfast Cereal D/WPackaged Meals D/W Hot Breakfast Cereal D/W

-CoffeeD/WTeaD/W WaterD/W

Excessive Usage/Habits (circle)

-Alcohol- Food- Sugar- Coffee - Salt

-Candy - Tea- Tobacco- Drugs (Illegal) - Computer Use

-Soft Drinks- Sex- Medication- Exercise - Television

-Other ______

Please list any significant physical traumas, including approximate date:

______

______

______

Please list any significant emotional traumas, including approximate date:

______

______

______

Please list any physical or emotional stressors that you have identified in your life:

______

______

______

Have you ever gone through a detoxification Y/N

If yes, please explain: ______

______

Please tell me what you are seeking relief for: ______

______

______

What aggravates your condition? ______

______

What improves your condition? ______

______

How long have you dealt with this condition? ______

Can you pin-point what caused this condition? ______

______

How do you cope with this day-to-day? ______

______

Do you feel stress in a particular part of your body? ______

Do you live alone or with others? ______

How would you describe yourself (introverted/extroverted/hyper/passive/etc) ____

______

How would you describe your family life? ______

______

Do you feel connected to nature? Y / N

Have pets? Y / N

Have plants? Y / N

Do you have a sense of personal spirituality? Y / N

Do you believe that you have an underlying purpose in life? Y / N

Do you have any creative outlets? Y / N

What is your outlook on life? ______

______

Do you exercise? Y / N

If yes, what type(s) ______

Allergies (please list) ______

______

Any exposure to radiation (x-rays, mammogram, microwave, etc.):______

______

Any exposure to toxic chemicals: ______

Please rate on a scale of 1-5, 5 being great and 1 being poor

Your physical health ______

Your emotional health ______

Your spiritual health ______

Your mental health ______

Have you ever seen a holistic practitioner before? Y / N

How was the experience? ______

What healing techniques/ modalities do you prefer? ______

Are you willing to change your lifestyle if you feel it would support your healing? Y / N

Is your occupation fulfilling? Y / N

Is your occupation stressful? Y / N

What are your objectives with these sessions? ______

______

What are your long-term health goals? ______

______

Please mark the box with the date(s) that apply to you-