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Health Intake Form
First name
*
Last name
*
Email
*
Phone
*
Birthday
Month
Month
Day
Year
Birth: Are you aware of any trauma to you or your mother's pregnancy with you, during labor or after she gave birth to you?
Was delivery long or difficult
*
no
yes
not sure
Were forceps or suction used?
*
no
yes
not sure
Were you breech?
*
no
yes
not sure
Were you cesarean?
*
no
yes
not sure
Did you have any major falls or accidents as a child?
no
yes
Did you have any major illnesses as a child? Please explain
Do you smoke cigarettes?
no
yes
Do you drink alcohol?
no
yes
Do you take recreational or therapeutic/medical grade drugs?
no
yes
marijuana
psilocybin
ketamine
other
prefer not to answer
Do you take over the counter drugs?
no
yes
Have you been in any accidents?
no
yes
Do you get good quality/quantity sleep?
no
yes
Have you had surgery to have organs removed or replaced?
*
Have you had any major surgeries?
*
Have you been diagnosed with a chronic illness?
*
Have you had any major injuries, accidents, or trauma?
*
Are you currently taking any medications?
*
What is your body telling you right now?
*
When did this start? Was there a significant event associated with that time?
*
What do you think the cause of this is?
What have you tried to heal it?
What activities aggravate this condition?
What activities lessen this condition?
Does this condition interfere with
work
sleep
routine
social life
What else is this stopping you from?
If this were to go away tomorrow, what would your life be like?
Are you living the life you'd like to be?
What would you change for the better?
On a scale of 1 - 10, how happy are you?
On a scale of 1 - 10, how much stress do you have in your life?
Are you ready to make changes in your life even if it is inconvenient to your current lifestyle?
What would you like to get out of these sessions?
*
Symptoms - Choose all that apply
neck pain
stiff neck
headaches
dizziness
fainting
ears ringing
balance loss
numb toes
chest pain
fever
loss of memory
migraines
thyroid issues
sciatica
numbness in fingers
shoulder pain
cold feet/hands
loss of smell/taste
cold/flu
allergies
pain in mid-spine
cold sweat
hearing problems
light sensitivity in eyes
menstrual pain
stress
not sleeping
fibromyalgia
nervousness
tension and irritability
fatigue/sleeping problems
depression
chronic fatigue
pins & needles/legs
shortness of breath
weight problems
stomach/digestive disorders
constipation/diarrhea
pins/needles in arms
difficulty breathing
lower back pain
knee pain
food sensitivities
gas/burping
frequent headaches
indigestion
heartburn/acid reflux
Other
Have you had any of these repeatedly, recently, or currently?
sadness
sorrow
grief
depression
loss
fear
anger
hatred
worry
doubt
despair
blame
shame
guilt
terror
horror
emotional trauma
physical trauma
nightmares
heartache
heartbreak
remorse
frustration
irritation
longing
envy
jealousy
stifled
blocked
manipulation
deceit
betrayal
disgust
disappointment
abandonment
overwhelm
rage
Something else?
How would you describe your mental health?
*
Is there anything else you'd like me to know?
Submit
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