New Client Intake

Thank you for taking the time to fill out this form and provide us with details of your health, goals and medical history. The more thorough and accurate your answers the easier it will be for us to figure out your most pressing underlying issue.  Do not hesitate to reach out if you need clarification on a question. Please allow time to complete this form in one sitting as your progress will not be save if you leave the page. You can download and print this form here.

Client Information
Name *
Address *
Phone (Day)
Phone (Day)
Phone (Cell)
Phone (Cell)
Phone (Night)
Phone (Night)
Date of Birth
Date of Birth
Health Concerns
Doctors? Self-Care?
Nutritional Status
Which of the following do you consume regularly?
Are you currently on a special diet?
Intestinal Status
Bowel Movement Consistency
Bowel Movement Color
Medical Status
Please check any of the following that apply to your history.
Health Hazards
Lifestyle History
For Women Only
Sexual History
Mental Health Status