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: *
Your answer
Date: *
MM
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YYYY
Telephone: *
Your answer
Email Address: *
Your answer
Birthdate *
Time and place if you wish to incorporate your astrological chart as part of the herbal integrated body system treatment plan.
Your answer
Height: *
Your answer
Weight: *
Your answer
Reason(s) for seeking consultation (include all physical, emotional, mental conditions/issues): *
Your answer
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.)
Your answer
Please list any medications, vitamins, herbs or supplements you take or have taken in past and for how long: *
Your answer
Please list any exercise/activities you do and how often: *
Your answer
Please list what you do to find peace of mind (de-stress) and how often: *
Your answer
What does your schedule consist of on an average day? Do you have a set routine or does your schedule change often? *
Your answer
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.
Your answer
Breakfast: *
Your answer
Lunch: *
Your answer
Dinner: *
Your answer
How often do you have a bowel movement and what is the consistency? *
Your answer
How often do you urinate and what color is it? *
Your answer
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? *
Your answer
Cramps/Pain? If so what do you do to relieve pain? *
Your answer
Number of Children and their ages? *
Your answer
Number of Pregnancies (whether full term or not) and when? *
Your answer
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
Your answer
Mother: *
If Applicable
Your answer
Father: *
If Applicable
Your answer
Maternal Mother: *
If Applicable
Your answer
Paternal Mother: *
If Applicable
Your answer
Paternal Father: *
If Applicable
Your answer
Maternal Father: *
If Applicable
Your answer
Do you smoke cigarettes or did you and for how long and how much a day? *
Your answer
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? *
Your answer
Are you more prone to holding things in or letting it all out? *
Your answer
Do you consider yourself more introverted or extroverted? *
Your answer
How would someone who cares about you describe your three greatest strengths? *
Your answer
How would someone who cares about you describe your three greatest weaknesses? *
Your answer
Describe four of the best times in your life... *
Your answer
What do you do to enjoy yourself/What makes you feel good? *
Your answer
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? *
Your answer
What do you want to see, think and feel differently about your life in the next two months? *
Your answer
What do you imagine your life looking like for you to be able to say, " I am completely fulfilled."?
Your answer
What would you like to be, have, or do differently by the completion of our work together?
Your answer
Are you willing to commit to your own wellness with Neko over the next 6 weeks?
Your answer
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