Client Intake Form
Inventory of how you are feeling now.
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Email *
Your Full Name *
Your Phone and or Text number *
Age: *
Relationship status: *
Required
Weight and Height *
Country of Residence: *
How many children? Their gender: *
Spiritual Beliefs: *
Pets? Type and how many *
Occupation: *
Hours of work per week? *
Eating Preference? What foods do you eat the most? *
Do you have allergies? What kind? *
What  are any significant health issues for Father/Mother/Siblings: *
Please list your main health concerns: *
Other concerns? *
What are your health goals: *
Do you have any serious illnesses, hospitalizations, surgeries? Describe: *
What are your symptoms? Any pain? list location and describe any pain, numbness, tingling *
How is your sleep? How many hours? Do you wake up at night or have trouble falling asleep? *
Any stiffness or swelling? Where? *
What are your bowel habits? *
Any digestive issues? Describe: *
Woman's Health: Are periods regular? How many days is your flow? How frequent? Painful or symptomatic? Birth control history?
Do you take any medications/supplements? Describe: *
Have you had any antibiotics recently or in the past? Describe: *
Have you had a recent blood draw? How many vials taken? *
Any healers/helpers/therapies in which you are involved? Describe: *
Do you exercise, what and how much: *
What foods do you eat in an average day for breakfast/lunch/dinner/snacks? *
Do you eat...
*
Required
Is any of this in your daily routine?
Have you read any Medical Medium books? If yes, which ones: *
Is Stress a problem in your life? *
Required
Anything additional you wish to share about your health or journey?
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