New Client Intake Form

Health Habits

Alcohol Habits:

Type

Amount

Frequency

Nicotine Habits:

Type

Amount

Interested in Quitting?

Vision Consumption:

Type

Glasses/Contact Lenses (Ounces)

Caffeine Consumption:

Type

Cups per Day

Energy Drink Consumption:

Type

Cans per Day

Carbonated Drink Consumption:

Type

Cans per Day

Favorite Drink:

Nutrition

Mix Food Diet:

I mix different types of food in my diet

Vegan/Vegetarian:

I am vegan/vegetarian

Keto/Carnivore:

I follow a keto/carnivore diet

Lactose/Gluten Intolerance:

I have lactose/gluten intolerance

Egg/Albumin Allergy:

I have an egg/albumin allergy

Corn/Soy Intolerance:

I have corn/soy intolerance

Other Dietary Restrictions:

Eating Habits

Skip Meals:

I skip meals regularly

Meals Per Day:

Intermittent Fasting:

I practice intermittent fasting

Meal Hours:

Eat For Comfort:

I eat for comfort

Cravings:

Sleep

Difficulty Falling Asleep:

I have difficulty falling asleep

Why Falling Asleep:

Difficulty Staying Asleep:

I have difficulty staying asleep

Why Staying Asleep:

Use CPAP:

I use a CPAP machine

Sleep Hours:

Feel Rested:

Exercise

Regular Exercise:

I exercise regularly

Exercise Frequency:

Over 30 Minutes Per Session:

I exercise for over 30 minutes per session

Exercise Types:

Weight Training:

I do weight training

Personal Information

Address

Contact Information

Occupation and Employer

Spouse Information

Referral Information

Wellness Concerns

How Long Have You Had These Symptoms?

Symptoms (Worst)

Symptoms (Best)

What Makes Your Symptoms Worse?

What Makes Your Symptoms Better?

Doctor/Specialist

Last Seen

Treatment Type

Results

Health Habits

Alcohol Habits:

Nicotine Habits:

Vision Consumption:

Caffeine Consumption:

Energy Drink Consumption:

Carbonated Drink Consumption:

Favorite Drink:

Nutrition

Mix Food Diet:

Vegan/Vegetarian:

Keto/Carnivore:

Lactose/Gluten Intolerance:

Egg/Albumin Allergy:

Corn/Soy Intolerance:

Other Dietary Restrictions:

Eating Habits

Skip Meals:

Meals Per Day:

Intermittent Fasting:

Meal Hours:

Eat For Comfort:

Cravings:

Sleep

Difficulty Falling Asleep:

Why Falling Asleep:

Difficulty Staying Asleep:

Why Staying Asleep:

Use CPAP:

Sleep Hours:

Feel Rested:

Exercise

Regular Exercise:

Exercise Frequency:

Over 30 Minutes Per Session:

Exercise Types:

Weight Training:

Other Exercise:

Prescription Medications

Herbs, Vitamins, Minerals, Food and Dietary Supplements

Drug or Food Allergies

Medical History

Cardiovascular/Circulatory System:

Digestive System:

Skin:

Musculoskeletal System: