Intake Questionnaire Name(Required) Date(Required) 1. Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 2. Email(Required) 3. Phone(Required)4. Marital Status 5. Date of Birth(Required) 6. Height/Weight(Required) 7. Have you recently lost or gained weight? Does your weight fluctuate?(Required) 8. Number of and ages of children, if any(Required) 9. Occupation(Required) 10. What are your reasons for seeking counseling(Required)11. What do you think are the causes of your problems(Required)12. Have you been treated for your health concerns with conventional medicine, psychology, psychiatry, herbs, acupuncture or other modality? Please Describe(Required)13. What would you like to change about your physical state? Your mental/emotional state? Your Life?(Required)14. Where, in your opinion, do good health energy, emotional harmony, and happiness come from?(Required)15. By whom were you referred to me 16. Please list a complete health history with dates(Required)17. List all medications, supplements or herbs you are taking with dosage; time of day taken; how long you've taken them; condition you are taking them for.(Required)18. Do you now or have you ever taken recreational drugs? If yes, what type of drugs, recency and frequency of use.19. How many times a day do you have a bowel movement? Are they loose, watery, formed, constipated? Do you experience gas, bloating, cramping or pain?(Required)20. How many hours of sleep do you get? Do you fall asleep easily and sleep soundly through the night without waking. What time do you go to bed and awaken?(Required)21. Do you exercise? What type? Frequency? How do you feel after exercise?(Required)22. How would you rate your energy on a scale of 1-10 with 10 being best?(Required) 23. Do you sweat easily? Do you sweat excessively? Do you experience afternoon or night sweats?(Required)24. Do you have any allergies to foods, medications, bites/stings, seasonal, animals, or other? Please describe.(Required)25. Do you experience headaches? Frequency?(Required) 26. Do you experience joint or muscle pain? Swelling? Please describe.(Required)27. Do you experience ringing in the ears?(Required) 28. Is your body temperature more on the cold or warm side?(Required) 29. In general, are you optimistic or pessimistic?(Required) 30. Do you experience persistent emotional problems; i.e., excessive fear, overly worried, anxiety, depression, excessive anger, acute irritability, low self-esteem, etc.?(Required)31. How often do you cook? Are you cooking for others?(Required) 32. Do you like to cook?(Required) 33. How often do you eat in restaurants? What types? Include take-out.(Required) 34. Do you eat meat, poultry, eggs, cow's milk products, sugar, artificial sweeteners, alcohol? Frequency of each.(Required)35. What type of diet do you follow? Average American, high protein, vegetarian, vegan, mediterranean, other?(Required) 36. List a typical day's eating, including snacks and beverages(Required)37. List five of your favorite foods even if you try to avoid them(Required)38. Do you experience food cravings? What type? Sweet, salty, high-fat or others? How do you satisfy them?(Required)39. Is your appetite strong or weak?(Required) 40. What are your strengths?(Required) 41. What do you like about yourself?(Required) 42. What are your weaknesses, if any?(Required) 43. Do you pray or meditate of use visualization techniques? How often? 44. At present are you seeing any health care professionals? What type? Medical doctor, specialist, psychologist, psychiatrist, acupuncturist, herbalist, massage therapist, physical therapist, or other?(Required)45. Would you like to receive my free e-newsletters, Whole Health Matters and Holistic Weight Loss, with tips and inspirations to help you get healthy and live your best life? Choose one or both. Provide email address if different from one previously given.(Required) Whole Health Matters Holistic Weight Loss I do not wish to receive either newsletter Your information is kept in the strictest confidence and is never shared with anyone. Your answers are encrypted for greater security.
