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Elements of Healing Health Intake Form
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First and Last Name
Your answer
What is your age?
Your answer
What is your gender?
Your answer
What is your date of birth?
Your answer
Contact number
Your answer
Email Address
Your answer
Emergency Contact
Your answer
Emergency Contact Number
Your answer
What are your primary health concerns?
Your answer
How long have you had these concerns?
Your answer
Have you seen any other healthcare providers for these conditions?
Your answer
Do you have any known medical conditions or diagnoses?
Your answer
Are you currently taking any medications or supplements?
Your answer
Do you have any allergies? (Please list them)
Your answer
Do you any eye or vision problems? (Floaters, blurry vision, dry eyes, etc)
Your answer
How is your body temperature? (Hot, cold, fevers, sweating, etc)
Your answer
How are your lungs and respiratory system?
Asthma
Difficulty breathing
Difficulty exhaling
Tightness in the chest
Phlegm
Hoarseness
Loss of voice History of pneumonia
Other:
Cardiovascular
Chest pain
Palpitations
High blood pressure
Low blood pressure
Irregular heartbeat
History of heart attack
Other:
Gastrointestinal
Bloating
Gas
Belching
Abdominal distension
Constipation
Diarrhea
Blood in stool
Candida/yeast infections
Irritable bowel syndrome
Hemorrhoids
No appetite
Nausea
Vomitting
Other:
Urogenital
Profuse amount of urine
Bladder control problems
Scanty amount
Cloudy urine
Frequent urine
Burning sensation
History of UTI
Impotence
Low sexual energy
Other:
Menstruation
Premenstrual tension
Bowel changes during menses
Feeling of fatigue before or during menses
History of yeast infections
Painful periods
Fibroids ovarian cysts
Endometriosis
Hysterectomy
Other:
Describe your typical daily diet: Breakfast, lunch, dinner, snacks, beverages.
Your answer
Do you have any dietary restrictions or preferences?
Your answer
How many times per week do yo eat fruits and vegetables?
Your answer
How many times per week do you eat processed foods?
Your answer
How many sugary drinks do you have per week?
Your answer
How many alcoholic beverages do you drink per week?
Your answer
How frequently do you move your bowels? (1 time per day, ever other day, etc?
Your answer
What does your weekly exercise routine look like?
Your answer
How many hours of sleep per night do you typically get?
Your answer
What daily stressors do you have? What stresses you?
Your answer
Do you smoke or do recreational drugs? How often?
Your answer
Do you experience any of the following?
Fatigue
Dizziness
Headaches
Shortness of Breath
Sweating
Thirst
Poor appetite
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Insomnia
Anxiety
Depression
Other:
Do you experience any pain or discomfort?
Yes
No
Clear selection
If yes, please specify the location and nature of your pain.
Your answer
Do experience any anxiety, depression or mood swings? Share how that feels and manifests, if you are comfortable.
Your answer
Is there anything else you would like to share about your health?
Your answer
What are your health goals?
Your answer
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