Client Intake Form

Client Intake Form

Address

City,State,Zip

Shipping Address

Write in your own words, your list of complaints or issues which concern you. What's wrong or bothering you? **Do Not Repeat What Others May have told you about yourself**

Select all that apply (Explain if check)

CancerDiabetesKidney FailureHIV/AIDS

HandicappedInfectious DiseaseTrauma

HepetitisCovid 19HerpesHeart DiseaseStrokeHypertensionMental Illness Emotional Upsets Digestive IssuesOther

Have you had a Covid nasal swab test? If so, list dates.

List 5 Related Goals or Abilities you desire to achieve.

Select all medications/drugs/substances being taken CoffeeTeaPrescriptionsAlcoholCocaineMarijuanaSupplementsVitaminsHerbsOther

Please list all prescriptions and supplements your are currently taking.

Are you currently under the care of a physician or other health care professional(s)? (If yes, please provide name)

List any major illness(with approx. dates)

List any surgery or operations (with approx. dates)

List any Past Accidents or injuries:

List any Allergies:

Martial Status SingleMarriedDivorcedWidowed

Describe health of your spouse

List Children (if any) with their age and sex. Are there any physical conditions or concerns?

Any family history of serious illness? CancerDiabetesHeartOther

Any household pets or other animals you or family members are in close contact with

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