Clinical Intake
Please complete this form and submit payment of $75 (1/2 of the consultation fee). When both the completed form and the initial payment have been received, we can begin your healing process.
Your Name
What's Your Name?
Your answer
Ethnicity
Email Address
What's the best way to contact you?
Your answer
Complete Address
Where do you live?
Your answer
Phone number
What's the best phone number for you?
Your answer
Age
How old are you?
Your answer
Sex
Occupation
What do you do for a living?
Your answer
Date of Birth and Birth Place
When and where were you born?
Your answer
Places you've lived
Where have you lived in your lifetime?
Your answer
Marital Status
What's your living situation?
Height
How tall are you?
Your answer
Weight
How much do you weigh?
Your answer
Major Health Events
What are the major events of your health history?
Please give specifics on any major health events listed above.
How old were you when the health events occurred and what happened during the events?
Your answer
Please list any present complaints. What are your current health concerns?
Let me know what you need help with or what your health complaints are at this time.
Your answer
Do you have allergies?
If so, please list below.
Your answer
Do you have trouble with any of the following? (Related to Comfort)
Please check the boxes that apply below.
Do you have trouble with any of the following? (Related to Sensations)
Please check all that apply.
Do you have trouble with any of the following? (Related to Digestion)
Please check all that apply
Do you have trouble with any of the following? (Related to Other)
Please check all that apply
Were you breastfed?
How's your appetite?
How are your thirst levels?
How are you sleeping and what's happening emotionally?
Check all that apply
How would you describe your energy levels?
Describe any pain, swelling or stiffness in your body.
Your answer
Please select the grains you currently eat below.
Choose all that apply.
What kinds of legumes do you eat?
Choose all that apply
What kinds of nuts do you eat?
Please list below.
Your answer
What kind of meats do you eat regularly?
Please list below.
What kind of dairy products do you consume?
Check all that apply
What kinds of nuts and seeds do you eat?
Choose all that apply
What kinds of sweeteners do you use?
Check all that apply
What kinds of fruits do you eat?
Check all that apply
What kinds of vegetables do you eat?
Check all that apply
Do you ever deep fry your food?
What kinds of oils do you use?
Check all that apply
What kinds of spices are you using now?
Go look at your spice rack and tell me what you have and use regularly.
Your answer
Do you have or have you had housepets during your life?
If so, please let me know which ones and what age you were at the time.
Your answer
Do you take any street drugs or prescription drugs? If so, which ones?
Please list below. Please note that I am bound by professional licensing and HIPAA to maintain confidentiality.
Your answer
What medications do you take regularly?
Please list all that apply, as well as the length of time you've been taking them.
Your answer
How does your urine typically look?
If you are a woman, do you have any trouble with your monthly cycles?
If you are a woman, how many children do you have?
Your answer
If you are a woman, what is your history with birth control pills or devices?
Please include the length of time that you have taken (or previously took) birth control pills or used implants, shots or other hormone-based birth control options.
Your answer
Have you had miscarriages or abortions before?
If you are a man, are you struggling with any reproductive or other male-specific issues?
Please take a snapsot of your face and email it to me at cleanclearbody@gmail.com.
This will help me to assess your condition even further.
What are your favorite tastes?
What are your favorite seasons?
What are your favorite colors?
Describe your current diet.
Are you currently on a diet?
Do you currently eat organic?
If you do eat organic, what percentage of your diet is organic, and how long have you been doing this?
Please explain below.
Your answer
Is there anything else you'd like to share with me?
Your answer
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