Intake form new clients only First Name Last Name Email Phone (###) ### #### DOB Current weight: Weight one year ago: Relationship status: Children: Pets: Where do you currently live? Occupation: Hours of work per week: Health Info Please list main health concerns: Other concerns / goals? At what point in your life did you feel the best? Any serious illness / hospitalizations / injuries? Are there any chronic health issues in your family? How is your sleep? On average how many hours do you sleep per night? Do you wake up at night? Any pain / stiffness / swelling? Allergies or sensitivities? Please explain: Womens Health Are your periods regular? yes no On average how many days is your flow? Painful or symptomatic? Please explain: Reached or approaching menopause? Please explain: Birth control history? Are you currently on it? If no, when did you stop? What kind? For how long? Do you experience yeast infections or utis? Please explain: Medical Info Do you take supplements or medications? Please list: Any healers, helpers, or therapies you are involved with? Please list: What role do sports and exercise play in your life? Food Info What foods did you often eat as a child? Breakfast, lunch, dinner, snacks: What is your food like these days? Breakfast, lunch, dinner, snacks: Will your family & friends be supportive of any food and/or lifestyle changes? yes no i'm not sure Do you cook? What percent of meals are home-cooked? Where do you get the rest from? Do you crave sugar, coffee, cigarettes, or have any major addictions? The most important thing I should do to improve my health is... On a scale of 1-10 how ready are you to invest in your health? Thank you!