Gaia's Garden New Consult Intake Form
This form must be completed before your initial consultation. Give yourself a good amount of time to consider the questions toward the end of this form. Yes, there are a lot of questions, but completing them in as much detail as possible ensures we will see the full picture of your wellbeing.
Email address *
Name *
First and last name
Birthdate *
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Email *
Phone number *
Occupation *
Partner status *
Is there a possibility that you are pregnant? *
Are you trying to become pregnant? *
Are you nursing? *
Do you currently smoke? *
Do you currently drink alcohol? Check all that apply. *
Required
How many glasses of alcohol do you consume in one WEEK? *
Do you drink any caffeinated drinks? *
Required
How many hours of sleep do you usually get per night? *
How many times per week do you exercise? And what type (yoga, running, lifting, dance, crossfit, etc.)? *
Do you have children? *
How many children? *
How many pregnancies? *
How were your pregnancies? (Of great importance is whether their pregnancies were stable or unstable.) *
Are you under the care of a physician (Can be any health care practitioner, traditional or orthodox)? If so, please list the condition(s) you are being treated for. *
Have you had a medical exam in the past year? *
Are you currently on medication? If Yes, please list medication. *
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