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Client Intake Form
Intake Form
The better this form is filled out, the best care is provided
because there will be no time wasted and we understand you
First and Last Name
Email
Cell Phone Number
How motivated are you to improve your health and lifestyle?
Low
Medium
High
Why are you motivated to improve health and lifestyle?
Gender
Female
Male
Place of Birth
Time of Birth
Are your parents living?
No, only mother
No, only father
No, both have passed
Yes, both parents living
Are your parents healthy?
Until what age did you live with your parents?
What is your relationship with your father?
What is your relationship with your mother?
Any conditions or diseases that effect your parents?
Do they use any substances like alcohol, drugs, marijuana, cigarettes?
What is your relationships with your sibling(s), if any? Are they healthy?
Education
High School
2 Year Degree
4 Year Degree
Graduate Degree
Current/Past Occupation
Stage
Working at home
In Transition
Unemployed
Retired
Are you happy with current occupation? Please share your ideal occupation.
General
Chronic stress
Jet-lag
Pregnancy
Aging
Obesity
Fatigue
Insomnia
Eyes (irritation, redness)
Dizziness/Vertigo
Nosebleeds
Rash/Skin irritation
New or changing moles
Anemia
Infection
Swollen lymph glands
Cancer
Digestive System
Nausea
Blood in stool
Diabetes
Irritable Bowel Syndrome
Colitis
Ulcer
Hemorrhoids
Diarrhea/constipation
Indigestion/heartburn
Respiratory System
Wheezing/shortness of breath
Chronic cough
Allergies
Asthma
Sinus infection
Lung disease
Reproductive System
PMS
Menopause
Menstrual problems
Musculo-Skeletal System
Generalized or all-over pain
Joint pain
Back or neck pain
Rheumatoid arthritis
Carpal tunnel syndrome
Psychological
Anxiety
Depression
Memory loss
Mood swings
Addiction
Neurological / Nervous System
Abnormal gait or falls
Headache severe/frequent
Seizures
Muscle weakness, TIA or stroke
Fainting/loss of consciousness
Localized numbness, tingling,
neuropathy
ADD/ADHD
Dyslexia
Auto-Immune
Fibromyalgia
HIV
Please List any major injuries, diagnoses, surgeries, hospitalizations
What current health issues (e.g. diabetes, stress, joint pain, etc.) do you want to focus on during this visit?
Please list the name, town, and condition being treated with any physicians that you see or have seen recently. (Please include Mental Health Professionals.)
List all prescribed and over-the-counter medications you take regularly. Include all supplements, vitamins or herbal products
Please list any complementary or alternative practitioners you see or have seen.
Yoga teacher
Ayurveda practitioner
Physical therapist
Chiropractor
Acupuncturist/Chinese
Naturopath
Herbalist
Massage Therapist
Please rate your stress level on a scale of 1–10 (10 is the highest):
Please rate your stress specifically with Work/Financial:
Please rate your stress specifically with Home:
Please rate your stress specifically with commute:
How well do you manage stress?
Not at all
Not well
Moderate
Very well
Extremely well
Please outline past difficult emotional experiences in your life.
How do you choose to cope with stress?
Have you used any of these substances in the last 30 days?
caffeine
tobacco
marijuana
alcohol
prescription drugs
recreational drugs
How many hours of sleep do you get each night?
4-6
6-8
8-10
10+
Describe any issues you have with sleep
How many meals do you eat per day?
1
2
3
4
5
6
7+
What are 3 typical meals you have each week?
Do you drink any of these?
caffeine
soda
sugared juices
Do you follow a consistent diet?
Yes
No
Do you currently have, or have you ever had, a problem with weight control?
Do you commonly...
over-eat?
under-eat?
How often do you eat out per week?
1-2 times per week
2-3 times per week
4-6 times per week
6-8 times per week
8-10 times per week
10+ times per week
How often do you eat home cooked meals per week?
1-2 times per week
2-3 times per week
4-6 times per week
6-8 times per week
8-10 times per week
10+ times per week
Describe your typical physical activity/exercise
Do you practice Yoga?
Yes
No
If so, how often per month?
0
1-2 per week
2-4 per week
5+ per week
Do you practice any breathing exercises or pranayama?
Yes
No
If so, how often per month?
0
1-2 per week
2-4 per week
5+ per week
How many hours per week do you dedicate to relaxation / hobbies?
0
1
2
3-5
5-7
7+
How many hours dedicated to conscious relaxation per day?
0
1 but not every day
1 per day
2 per day
3 per day
4+ per day
How many hours per week do you dedicate to creative pursuits (e.g., time in nature, music, writing, painting, etc.)?
0
1 but not every week
1 per week
2 per week
3 per week
4+ per week
How often do you vacation?
0 times in the last 2 years
1-2 times per year
3-4 times per year
5-6 times per year
7+ times per year
When and where was your last vacation?
How often do you meditate?
0
1 time per month
1-2 times per week
3-4 times per week
5-7 times per week
Do you meditate on your own or in a group?
Mainly by myself
Mainly in a Group
I don't meditate
What school of meditation (life philosophy) do you practice?
Marital Status
Married
Single
Divorced
How long in your current relationship, if any?
What are your living arrangements?
How many children if any do you have? And the children's ages
Which relationship(s) fulfill and/or empower you?
How many close friends do you have?
0
1
2
3
4
5
6+
How often do you interact with community groups/friends/family?
Do you have any pets?
Do you participate in any charitable activities?
Do you consider yourself to be
social
moderately social
reclusive
isolated
Do you have any difficulty communicating with
most everyone
partner
children
friends
co-workers
other
Do you have specific health concerns about your current home or environment (quality of air, water, EMF, noise, etc.)?
Have you had hazardous environmental or occupational exposures? If yes, please describe.
What brings you joy, meaning and inspiration?
Do you feel connected with your inner Self/Supreme Being?
Yes
No
What is your present method for spiritual connection (meditation, prayer, time in nature, worship, kirtan, Yoga asanas, satsang, etc.)?
If time and money were not an issue, describe the things you wish to do in your life:
What skills, activities and qualifications would you like to have to fulfill your life?
Is there anything else that would be helpful for us to know about you?
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