Client Intake Form

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Birthday

I ask for this because I need to know where you are in the age lifecycle.

Sleep

The purpose of this section is to identify your sleep patterns so we can concentrate what to do first.

How many hours of sleep do you average per night?(Required)

Do you wake up in the middle of the night?

Do you have trouble falling asleep?

Is this new for you? When did it start?

Do you take naps?

Movement

Share how you like to move and how often to build a better stronger body that looks and feels good!

How often do you move?(Required)

Move what's that? You mean like exercise?

1-3 times per day

4 or more

What kind of movement or exercise do you like to do ?

Do you have an injury that limits or stops movements?

Medications

Are you taking any medications at this time? If so please list.(Required)

How long have you been taking them?

Do you have any medical conditions?

Have you taken antibiotics ? How often?

Do you take over the counter medications? Please list.

How often are you using over the counter medications?

Do you take any vitamins or supplements? Please list .

Eating and Foods

Finding the foods that work for you and with you feel better!

What food do you like to eat?(Required)

Do you eat breakfast and what do you eat?

What foods make you feel good ?

What foods disagree with you or make you feel bad?

What happens when you eat those foods?

Stress

Let's discover that causes stress and how your body handles it.

What is your stress level rank from 1 to 5 with 5 is the most stressed.(Required)

How do you manage your stress?

Are you taking any medications (over the counter or prescription)

Mood

Mood changes are signals from our brain telling us what it needs.

Do you have mood swings?(Required)

How often does this occur?

Are you tired? Are you anxious ? Please describe.

Phone

Name

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