New Client Intake Form
Welcome to Refresh Your Soul. Please, take some time to fill out this intake form.
Email address *
First & Last Name *
Your answer
Date *
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Address *
Your answer
City *
Your answer
Zip *
Your answer
Phone (Cell) *
Your answer
Phone (work) *
Your answer
Email Address *
Your answer
Occupation *
Your answer
No. of Children *
Your answer
Marital Status *
Your answer
Date of Birth *
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How did you hear about us? *
Client History
Are you currently or in the last year, under a physicians care? *
If yes, please specify: *
Your answer
Have you had any of these health problems in the past or at present? Please select all that apply. *
Required
List any medications and vitamins that you take regularly: *
Your answer
List any known allergies:
Your answer
How many bowl movements to you have daily/weekly? *
Do you have any skin conditions pertaining to your face or body? *
If yes, please specify: *
Your answer
Do you smoke? *
Have metal implants or pacemakers? *
Follow a strict diet? *
Exercise regularly? *
Have regular sleep patterns? *
Moisture Hydration
How much water do you consume daily (in ounces)? *
Your answer
How many caffeinated beverages do you consume daily? *
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Coffee
Tea
Soda
Energy Drink
Do you take diuretics? *
How many alcoholic beverages do you consume weekly? *
Do you ever experience these conditions on your skin? *
Do you burn in moderate sunlight? *
Do you blush easily when nervous? *
Do you have a tendency to redness? *
Have you ever suffered any sinus problems? *
Nerve Activity
Do you take any stimulants or slimming tablets? *
What level do you consider your pain threshold to be? *
Have you ever experienced any claustrophobia? *
What type of massage pressure do you like? *
Colon Information
Have you ever had a colonic before? *
Is yes, when?
Your answer
Have you ever done colon cleansing in the past? *
Do you strain to have a bowel movement? *
Do you use stool softener or laxative? *
If yes, herbal laxative or suppository? *
Do you have hemorrhoids or rectal problems? *
If yes, please specify:
Have you ever had rectal bleeding? *
If yes, please explain:
Your answer
Have you ever had a colonoscopy? *
If yes, please explain:
Your answer
Have you ever had Sigmoidoscopy? *
If yes, please explain:
Your answer
What do you feel a colonic will do for you? *
Your answer
Is there anything we should know about concerning your colon? *
Your answer
What You're Eating
How many servings do you eat a week? *
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Vegetables
Whole Grains
Beans
Legumes
Chicken, Fish
Fruit
Bread
Bagels
Pasta
Muffins
Baked Goods
Candy
Cake, Cookies
Red Meat, Pork
Dairy
SOy Products
Fried Foods
Stress Level
Please select, on a scale of 1-10, 1 being the least and 10 being the highest level of stress in your life right now: *
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Column 11
Work
Family
School
Friends
Loved Ones
Kids
Personal
Illness