Custom Therapeutic Blend Intake Form
Gaia Goddess Healing
Holistic Wellness Center
gaiagoddesshealing.com
Email address *
Client Name
Your answer
Date of birth
Your answer
Gender
Marital Status
Occupation
Your answer
Please briefly comment on current status or concerns of over-all health.
Your answer
Identify the condition and/or physician's diagnosis.
Your answer
What is your desired outcome of treatment?
Your answer
Please describe history of the present condition.
Is this a recurring issue, have you noticed a pattern, related problems, etc?
Your answer
Please list or describe your symptoms (include timeframes).
Your answer
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.
Your answer
Please indicate any other significant medical conditions.
Your answer
Please list any relevant birth history.
(vaginal birth, Cesarean, complications, early or late birth, etc.)
Your answer
Please list significant family health history.
Your answer
*Women
Please check one of the following:
Please list any Medications/Herbs/Vitamins
List dosages as well.
Your answer
Please list and/or describe any allergies and reactions.
Include topical as well as oral medications and environmental allergens.
Your answer
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.
Your answer
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.
Your answer
Please list and or describe your hobbies.
Your answer
Please briefly discuss your support systems.
Friends, church, support groups, etc.
Your answer
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