INTAKE FORM

Intake Form

First Name

Last Name

Phone

Basic Info

Occupation?

Hours per week?

Do you know your purpose?

Yes

If so, what is your porpose?

Do you live your purpose?

What are your primary sources of community?

What are your main health concerns?

Will family and/or friends be supportive of your desire to make lifestyle changes?

Any other information or concerns?

Health History

At what point in your life did you feel the best?

Any serious illness/hospitalizations/injuries?

How is the health of your father?

How is the health of your mother?

What is your ancestry?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation / Diarrhea / Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any medications or supplements?

Any healers, helpers or therapies with which you are involved? Please list:

What role do sports and exercise play in your life?

Food

Breakfast

Lunch

Dinner

Snacks

Beverages

Other

Do you crave sugar, coffee, cigarettes or have any addictions?

If so, explain

What percentage of your food is home cooked?

Where do you get the rest from?

What is the most important thing you should change about your diet to improve your health?

How many nights in the past week did you have one drink (alcohol) or more?

What percentage of your day is your phone out of reach and/or on airplane mode?

Finish up

What role, if any, does spirituality play in your life?

What goals do you have for the next year?

What are some life goals? (think big)

What fear is holding you back most in life?

What is your biggest fear that you would like to break through this year?

Is there anything else you'd like to share?

Thanks for submitting!