Client Intake Form (Confidential-for Practioner's use only)
Name		Date	Email__________________
Address		D.O.B.
		Occupation
Phone:  Home	Cell                                       Work
Emergency Contact (name & number)
Relationship Status	#Children		Referred by
Physician (name & number)
Therapist (name & number)
Reason for Visit
Current/Previous Treatment (for above)
Current Medications
Current Complementary Therapies/Supplements
Eating Habits/Diet
Amount Daily Intake:  Water	Caffeine	Alcohol	Cigarettes
Exercise Routine
Please mark the following area of disease or symptoms as 'C' for current, 'P' for Past, and 'CH' for
chronic. Explain if necessary.
Depression	Hyperthyroid	Heart Attack	Liver Disorder
Eating Disorder	Hypothyroid	Heart Failure	Ulcers
Mood Swings	Epilepsy	Hypertension	Bladder Infection
Substance Abuse (type)	Dizziness	Stroke	Kidney Stones
AIDS/HIV	Insomnia	Bronchitis	Sex. Trans Dis(type)
Allergies	Migraines	Emphysema	Endometriois
Cancer(type)	Arthritis	Pneumonia	Pregnancies(#&'C')
Fatigue	Back Pain	Tuberculosis	Miscariage(#)
Fibromyalgia	Carpal Tunnel	Constipation	Abortion(#)
Fungal Infections(type)	Gout	Diabetes
Herpes(type)	Skin Disorder(type)	Diarrhea(chronic)	Other:
Lyme Disease	Earaches(chronic)	Gastritis
Mononucleosis	Headaches	Hepatitis
Adrenal Insuf.	Jaw Pain	Hypoglycemia
Pituitary Dysf	Angina	Jaundice
Please list any injuries you had and have:
Please list any surgeries you had or know you will have:
Please list any traumatic or life threatening events that occurred in your life, and when they happened:
What do you hope for and what are your expections from this healing today and long-term?
Is there anything else you want to share or want me to know?