CLIENT INTAKE FORM Name * First Name Last Name Email * DOB * Current medications and or supplements? * Describe any illnesses, emotional stresses, or out of ordinary health experiences in the past 3 months? * Do you have any chronic Health Concerns? * blood pressure, cholesterol, thyroid, heart issues, etc. What are your health related goals? * blood pressure, cholesterol, thyroid, heart issues, weight, improved health, decrease fat, increase performance, muscle gain, etc. Do you follow any special diet or dietary restrictions? * ex. vegetarian, keto, gluten-free, intermittent fasting, dairy free, etc Any allergies? * Preferred Contact Method * Phone Email Text How often do you exercise? * Frequently Sometimes Rarely Never Sensitivity to cold Scale of 0-5 is, zero being not at all and 5 being severe Poor blood circulation Scale of 0-5 is, zero being not at all and 5 being severe Difficulty losing weight Scale of 0-5 is, zero being not at all and 5 being severe Morning fatigue Scale of 0-5 is, zero being not at all and 5 being severe Constant fatigue Scale of 0-5 is, zero being not at all and 5 being severe Depression Scale of 0-5 is, zero being not at all and 5 being severe Headaches Scale of 0-5 is, zero being not at all and 5 being severe Poor concentration Scale of 0-5 is, zero being not at all and 5 being severe Ear/nose throat infection Scale of 0-5 is, zero being not at all and 5 being severe Puffiness in face Scale of 0-5 is, zero being not at all and 5 being severe Constipation Scale of 0-5 is, zero being not at all and 5 being severe Heartburn Scale of 0-5 is, zero being not at all and 5 being severe Nosebleeds Scale of 0-5 is, zero being not at all and 5 being severe Morning joint stiffness Scale of 0-5 is, zero being not at all and 5 being severe Joint/tendon pain Scale of 0-5 is, zero being not at all and 5 being severe Hoarse Voice Scale of 0-5 is, zero being not at all and 5 being severe Ringing in Ears Scale of 0-5 is, zero being not at all and 5 being severe Hypoglycemia Scale of 0-5 is, zero being not at all and 5 being severe Dry Skin Scale of 0-5 is, zero being not at all and 5 being severe Brittle Nails Scale of 0-5 is, zero being not at all and 5 being severe Hair loss Scale of 0-5 is, zero being not at all and 5 being severe Slow growing hair Scale of 0-5 is, zero being not at all and 5 being severe Easily Stressed Scale of 0-5 is, zero being not at all and 5 being severe Feel burned out Scale of 0-5 is, zero being not at all and 5 being severe Tired but unable to rest Scale of 0-5 is, zero being not at all and 5 being severe Crave sugar Scale of 0-5 is, zero being not at all and 5 being severe Crave salt Scale of 0-5 is, zero being not at all and 5 being severe Heavy/irregular periods Scale of 0-5 is, zero being not at all and 5 being severe Excessive sweating Scale of 0-5 is, zero being not at all and 5 being severe Night sweats Scale of 0-5 is, zero being not at all and 5 being severe Bladder infections Scale of 0-5 is, zero being not at all and 5 being severe Anxiety Scale of 0-5 is, zero being not at all and 5 being severe Irritability Scale of 0-5 is, zero being not at all and 5 being severe Fluid retention Scale of 0-5 is, zero being not at all and 5 being severe Decreased stamina Scale of 0-5 is, zero being not at all and 5 being severe Poor sleep quality Scale of 0-5 is, zero being not at all and 5 being severe Tense muscles Scale of 0-5 is, zero being not at all and 5 being severe Eye dryness Scale of 0-5 is, zero being not at all and 5 being severe Diarrhea Scale of 0-5 is, zero being not at all and 5 being severe Gas Scale of 0-5 is, zero being not at all and 5 being severe Bloating Scale of 0-5 is, zero being not at all and 5 being severe Frequent UTI’s Scale of 0-5 is, zero being not at all and 5 being severe Kidney Stones Scale of 0-5 is, zero being not at all and 5 being severe Thank you! .
