Client Intake Form

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Time of Birth

Place of Birth*

Home Phone*

Cell Phone

Email*

Number of organs removed

(e.g. tonsils, appendix, etc. - count ovaries individually)

Number of prescription or over the counter medications taken daily

Number of times a day you smoke or chew tobacco

Number of steroid type drugs taken in the past year, include inhalers

Number of silver amalgam type dental fillings in current teeth

Number of street drugs used each month

Number of known allergies

Number of persistent thoughts by category e.g.; work, relationship, health issues, etc.

On a scale of 1-100% how much do you feel it is your responsibility for your health*

Amount of fat in your diet by % (average American diet is at 40%)

Rate overall stress level (1–10 with 10 highest)

Please enter a number from 1 to 10.

Number. of times a week you exercise 20 minutes or more

Number of alcoholic drinks consumed daily, or average out for week

Number of caffeine products consumed daily e.g.; coffee, tea, Red Bull, etc.

Number of toxic exposures e.g.; CT scan, chemotherapy, radiation therapy, etc.

Number of past injuries emotional & physical – include surgeries

Number of past major infections that required hospitalization or long term medication

Number of glasses of pure water you drink on average per day

Do you feel you are overweight? If so, by how much?

Do you wear a pacemaker?*

Are you pregnant?

Have you ever had electro-shock therapy?

Signature of client - (parent for minor)*

Entering you name below functions as a "digital signature".

Name

This field is for validation purposes and should be left unchanged.