Healing Paths Intake Form
Thanks so much for sharing your important information with me to help assist in treating you holistically. All that you share will remain confidential and used only for my records. Please take your time with each question and be honest for the best results. Thank you. -Neko
Name: *
Date: *
MM
/
DD
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YYYY
Telephone: *
Email Address: *
Birthdate *
Time and place if you wish to incorporate your astrological chart as part of the herbal integrated body system treatment plan.
Height: *
Weight: *
Reason(s) for seeking consultation (include all physical, emotional, mental conditions/issues): *
Do you have or did you have any pre-existing conditions and if so please describe them: *
(i.e. migraines, depression, high/low blood pressure, irregular menstruation, digestive issues, addictions, Hepatitis A B or C, HIV/Aids, Cancer, Bi-Polar, PTSD, High Cholesterol, Hemophilia, etc.)
Please list any medications, vitamins, herbs or supplements you take or have taken in past and for how long: *
Please list any exercise/activities you do and how often: *
Please list what you do to find peace of mind (de-stress) and how often: *
What does your schedule consist of on an average day? Do you have a set routine or does your schedule change often? *
What do your meals consist of on an average day? Including beverages please ie. How much water, soda, coffee, beer, tea.
Please answer under the appropriate meal times.
Breakfast: *
Lunch: *
Dinner: *
How often do you have a bowel movement and what is the consistency? *
How often do you urinate and what color is it? *
Date of Last Menses: or When Menopause Began: Please describe your menstrual cycle (ie. Heavy, Light, Irregular, Regular): How many days do you bleed? And how many days between periods? Is blood thick/thin/red/brown, etc? *
Cramps/Pain? If so what do you do to relieve pain? *
Number of Children and their ages? *
Number of Pregnancies (whether full term or not) and when? *
Please list any conditions that you feel important to add that your family has or has had (including blood pressure, diabetes, tumors, cancer, heart conditions, addictions):
List conditions under the appropriate person, leave blank if N/A
Mother: *
If Applicable
Father: *
If Applicable
Maternal Mother: *
If Applicable
Paternal Mother: *
If Applicable
Paternal Father: *
If Applicable
Maternal Father: *
If Applicable
Do you smoke cigarettes or did you and for how long and how much a day? *
Do you drink alcohol: *
Required
Have you tried any of the following recreational drugs and how many times. *
Never
1 - 3
3-10
10-20
20 or more
Inhalants (Gas, Whippits, etc)
Marijuana
Cocaine
Mushrooms
Acid / LSD
Ecstasy
Heroin
Crack
Ayahuasca
Peyote
Ibogaine
Pharmaceuticals/Pills 
Do you tend to run hot or cold? *
Are you more prone to holding things in or letting it all out? *
Do you consider yourself more introverted or extroverted? *
How would someone who cares about you describe your three greatest strengths? *
How would someone who cares about you describe your three greatest weaknesses? *
Describe four of the best times in your life... *
What do you do to enjoy yourself/What makes you feel good? *
If today were the day that you could sit under a wish fulfilling tree and have any one wish you wanted, just for you, what would you wish for? *
What do you want to see, think and feel differently about your life in the next two months? *
What do you imagine your life looking like for you to be able to say, " I am completely fulfilled."?
What would you like to be, have, or do differently by the completion of our work together?
Are you willing to commit to your own wellness with Neko over the next 6 weeks?
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