Client Intake Form (Confidential-for Practioner's use only)
Name   Date Email__________________
Address   D.O.B.    
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?