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Client Intake Form

Please fill out the following form and submit it before your first appointment.

Do not close, refresh or navigate away from this page while you are completing your form.

A. Basic Information

B. Health Goals

C. Health History

D. Lifestyle

What is your daily (approximate) consumption of:

Do you smoke? (check all that apply):
How would you describe your current activity/exercise level?
Is your weight stable or up and down?
Are you constantly dieting?
Do you experience PMS:
Do you have a history of yeast/bladder infections:
Fall asleep easily?
Wake up during the night?
Do you feel rested when waking?
Restless sleeper?
Do you snore?:
Do you have sleep apnea?:
Do you have job-related stress?
Do you experience periods of high stress?

Do you use any of the following? And for how long each day?

E. Symptoms

Please select any symptoms you’re currently experiencing, experience often, or have recently experienced:

Sleep Habits

F. History with other practitioners

G. Signature

Please complete a 3-4 day Daily Food Record and submit it at least 24 hours prior to your first appointment. 

Thanks for submitting!

You will receive a confirmation email shortly

C. Health History
D. Lifestyle
E. Symptoms
F. Practitioner History
G. Signature
A. Basic Info
B. Goals
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