Human Intake Form

Please fill out and submit this form at least 48 hours prior to your initial appointment. Required fields are marked with a red asterisk. The information you provide is held as private and will not be shared without your expressed permission.
  • General Information

  • Presenting Issue(s)

  • Please specify what each medication is for and duration of treatment.
  • Lifestyle

  • Employment, child rearing, caregiver
  • Please list activities and amount of time you engage in them per week.
  • Are you on a special diet?
  • Food and environmental
  • Daily, weekly, occasionally
  • Medical History

  • Divorce, deaths, depression, abuse, accidents and other significant events.
  • If so, include any diagnosis and current medications.
  • High/low blood pressure, disorders, attacks, past surgeries, pacemaker, etc.
  • Auto-immune, endocrine, musculoskeletal, neurological, digestive, respiratory, reproductive, urinary, ear/nose/throat, infectious diseases, vascular, etc.
  • Healing Session Preparation