Client Intake Form

  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • Use the dropdown + sign to add more rows.
    Signficant IlnessesInfectious DiseasesSurgeriesTrauma 
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    MedicationsFoodEnvironmentalChemicalOther 
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    MotherFatherGrandparentsSiblings 
  • Please enter everything currently taken, and the reason you are taking it, using the dropdown + sign to add more rows.
    Meds/Herbs/SupplementsPurpose taken 
  • Please indicate amount of use if applicable.
    Smoking/TobaccoAlcoholRecreational Drugs 
  • Please describe your current living situation, work, hobbies, support networks and exercise routine.
  • Please check all that apply.
  • Please list locations of pain and describe, using the + sign for drop-down additions.
    LocationIntensity (scale 1-10)Quality (sharp, dull, continous, intermittent, roaming, etc)What aggravatesWhat relieves 
  • Please check all that apply.
  • Pleases check all that apply
  • Please check all that apply.
  • Please select all that apply.
  • Please check all that apply.
  • Please check all that apply.
  • Please check all that apply.
  • Please check all that apply.
  • Please check all that apply.
  • Please check all that apply.
  • Please check all that apply.
  • # Pregnancies# Miscarriages# Abortions# Premature BirthsAge of MenarcheAge of MenopauseLast PAPLast Mammogram 
  • Length of CycleDuration of Flow 
  • Please answer in as much detail as possible.
  • This field is for validation purposes and should be left unchanged.

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