Print Intake Form Personal Information Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact Information First Name Last Name Phone Number (###) ### #### Health History How would you currently rate your overall health? Excellent Very good Good Fair Poor What do you attribute to your current health condition? Date of last physical: MM DD YYYY Current health care professionals? (Names not required) Select the areas that are of concern for you: Addiction Allergies Anger Anxiety Anxiety Attacks Depression Diet/Nutrition Elimination Emotional Health Fatigue Finances Headaches Hormonal Issues Major Life Change Memory Mental Health Mood Swings Personal Direction Personal Relationships Physical Health Physical Pain Safety Sleep Spiritual Trauma/PTSD Water Intake Work Current State These questions will help provide insight into your current state. Please answer as best as you can. What is your greatest gift? Describe a time when your greatest gift served you well? In the last 3 days, tell me what time you went to bed and when you think you fell asleep? In the last 3 days, tell me about your movement practices (aerobic, strength, flexibility) Do you know of any familial or ancestral patterns that may be contributing to your current situation? Do you have any limiting beliefs that consistently come up in your life? When was one of the happiest times in your life? What did it feel like? Describe your favorite place - a place where you feel peaceful, safe and completely relaxed. What change would you like to see in yourself as a result of working together? Thank you!
