Custom Therapeutic Blend Intake Form
Gaia Goddess Healing
Holistic Wellness Center
Email address *
Client Name
Your answer
Date of birth
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Marital Status
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Please briefly comment on current status or concerns of over-all health.
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Identify the condition and/or physician's diagnosis.
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What is your desired outcome of treatment?
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Please describe history of the present condition.
Is this a recurring issue, have you noticed a pattern, related problems, etc?
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Please list or describe your symptoms (include timeframes).
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Please describe your sleep pattern.
Include intended sleep schedule vs. actual sleep pattern, number of hours each night, number of times you wake at what hours, physical/emotional feelings when awakened, etc.
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Please indicate any other significant medical conditions.
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Please list any relevant birth history.
(vaginal birth, Cesarean, complications, early or late birth, etc.)
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Please list significant family health history.
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Please check one of the following:
Please list any Medications/Herbs/Vitamins
List dosages as well.
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Please list and/or describe any allergies and reactions.
Include topical as well as oral medications and environmental allergens.
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Please describe your diet.
Include type of diet (omnivore, vegetarian, vegan, gluten-free, etc), frequency of meals, eating patterns (esp. describe meals close to bedtime).
Your answer
Please describe your current mental/emotional status.
Ex. Work related strees, Difficulty focusing on studies, etc.
Your answer
Please describe your personality/disposition.
Feel free to include differences in how you describe yourself as compared to how your friends describe you.
Your answer
Average number of cigarettes smoked per day
Average number of caffeinated beverages per day
Average number of alcoholic beverages per *week*.
Living environment
Please check all that apply
Number of family members/roommates (aside from you) living in the home.
Are your pets allowed to sleep in your room? If so, please describe where they sleep and any relevant disturbance this has caused at any time.
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Do you currently sleep with any of the following aids?
Check all that apply.
Please check the highest level of education completed.
Please describe your activity level.
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Please list and or describe your hobbies.
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Please briefly discuss your support systems.
Friends, church, support groups, etc.
Your answer
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