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Client Intake Form
Please fill out and submit this for at least 24 hours prior to your appointment
Name
Email
Home Phone
Rate your general health
*
Required
Very Poor
Poor
Good
Excellent
What do you need help with?
*
Required
Nutrition
Spiritual Coaching
Energy Levels
Overall Physical Health
Mental Health & Wellness
Other
What is your most important health goal?
Do you regularly consume any of the following?
*
Required
Alcohol
Tobacco
Coffee
White Sugar
Pharmeceuticals
Soda
White Flour
Sweetners e.g Nutrasweet
Do you have experience with the following:
*
Required
Homeopathy
Spinal Flow
Biofeedback
Acupuncture
Herbal Remedies
Reiki Energy Healing
Animal Care
Access Bars or Facelift
Spiritual Coaching
Auricular Therapy
Harmonic Light Therapy
Emotox Light Sensitivity
Electro acupuncture
Other
Briefly describe your diet
LIst all dental surgeries and procedures; root canals, crowns, materials used etc. Please indicate year of treatment
List all current medications for diagnosed illness, including the illness
List all surgeries, injuries, accidents. Include year of injury and treatment
RATE YOUR ENERGY LEVELS
MORNING
*
Low
Medium
High
Very High
AFTERNOON
*
Low
Medium
High
Very High
EVENING
*
Low
Medium
High
Very High
Date of last dental visit
List all current supplements you are taking
Please indicate if you have had any of the following removed:
*
Tonsils
Adenoids
Appendix
What is your activity level?
*
Light (10-15 min)
Moderate (15-30 min)
Heavy (40-80 min)
What kind of physical activity to you participate in?
*
Stretching
Aerobics
Weights
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