Client Intake Form

General Information

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(This information is private and confidential and will only be use by our team to help in your treatment holistically.

First name

Last Name

Contact Number

Contact Email

- Presenting Issues -

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Lorum Ipsum

Past medical issues

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Please enter any major Illnesses you have been affected by in the past.
Example: TB, Shingles, Hepatitis, Arthritis, Thyroid Disease, Anaemia, Stroke, Diabetes, High Blood Pressure, Heart Disease, Glandular Fever etc.

Operations

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Please tell us about any operations you have had.

Accidents/injuries:

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Please tell us about any accidents you have been involved in or injuries you have suffered from. If none, please put none.

- Social and Emotional History -

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Please tell us a bit about your social and emotional history.

Pre-natal Stress:

Birth History:

Were you breast fed?If your answer was yes, how long for?

Do you have any siblings?

Childhood Illnesses: i.e. “Did you have a healthy, happy Childhood?” If no, please tell us briefly about it.

Relationship with Food?

Known Allergies:

Family History:

Current Sources of Stress:

Exposure to Lyme Disease:

Occupational History:

Parents’ Occupational Histories:

Known Chemical Exposure

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Please tell us if you have had any Chemical Exposure.
Example: aftershave, agricultural chemicals, air fresheners, artificial sweeteners, botox, deodorants, fake tan, fluoride, frequent flying, hair dye/gel, implants, insecticides, makeup, mothballs, mould, nail varnish, paint, perfume, pesticide treatments, photocopier ink, piercings, scented candles, tattoos, weedkiller

Menstrual Cycle:Are you on the Pill?If your answer was yes, how long for, which pill?

HRT?

If your answer was yes, how long for?

Antibiotic History:

Dental Interventions:

Obstetric History:

Tropical Travel:

Vaccinations:

Known EMF/radiation Exposure:

Do you use a microwave oven?

Exercise Routine

Sleep Routine:

Whats your pain threshold like:?

Do you have slow wound healing?

Any current or previous Test Results:

Previous Diagnoses

- Drugs, supplements and medicines -

Supplements

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Please tell us about any supplements you took in the past, and/or currently take.

Past Supplements

Current Supplements

Alternative Medicines, Eg herbs, homeopathy:

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Please tell us about any medicines you took in the past, and/or currently take.

Past Medicines

Current Medicines

Prescription Drugs:

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Please tell us about any prescription drugs you took in the past, and/or currently take.

Past Prescription Drugs

Current Prescription Drugs

Street Drugs:

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Please tell us about any prescription drugs you took in the past, and/or currently take.

Past Street Drugs

Current Street Drugs

- 3 day diet diary -

Week day 1

Week day 2

Weekend

Breakfast

Lunch

Dinner

Snacks

Drinks

Anything to add?
Any other significant information you wish to share? Just let us know in the box below.

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Client Release and consent to assessment and treatment as required:

* By ticking this box I consent to my information being used for assessment and treatment.

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A Holistic Approach