Intake Assessment
New Client Questionnaire
Email address *
First Name *
Your answer
Last Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Main complaints: *
Your answer
How long have you suffered with this problem *
Your answer
Any other complaints:
Your answer
Would you like improvement with any of the following?
What have you tried doing to resolve this problem that DID NOT work?
Your answer
Have you become discouraged or stressed about handling this problem?
Your answer
How does this problem interfere with the following areas in your life?
Work:
Your answer
Family:
Your answer
Hobbies:
Your answer
Life:
Your answer
When it's at it's worst, how much older does this make you feel?
Your answer
Do you know how this problem may have started?
Your answer
What effect does this have on your body functions? *
Your answer
Are you here visiting us to: *
How have you taken care of your health in the past? *
Required
How did the previous methods work for you?
Your answer
What are you afraid this might be or will be affecting without change? Select all that apply.
Are there any health conditions you are afraid this might turn into? Select all that apply.
Where do you picture yourself being in the next 3-5 years if this problem is not taken care of? Please be specific. *
Your answer
What would be different or better without this problem? Select all that apply. *
Required
If you were to sit down and discuss your life 3 years from now and look back at today, what would have to happened for you to be happy with your progress? (Please take your time and don't sell yourself short! Include anything that is part of your happiness, whether health, family, work, finances, travel, marriage or bucket list.) *
Your answer
What potential barriers do you foresee that would prevent these things from happening? *
Your answer
Do you feel it is possible to eliminate or prevent these potential barriers? *
Your answer
What are your strengths that will enable you to accomplish your goals? *
Your answer
How important is it for you to resolve your health concerns? *
Not important
Very important
Do you feel that you are coachable and would enjoy a mentor in helping you? *
Not important
Very important
Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals? *
Not important
Very important
Please complete form prior to your scheduled appointment.
Thank you!!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service