Appointment Intake Form

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

Receive Texts

No
Yes

Birth Date

Height (ft/in)

Weight (lbs)

Gender at Birth

What is the main reason for your visit today?

1000 words or less.

Are there any other health issues you would like to address?

1000 words or less.

How would you rate your overall health on a scale of 1-10?

(1= poor, 10= excellent) Selected Value: 5

How would you rate your overall outlook on life on a scale of 1-10?

(1= negative, 10= positive) Selected Value: 5

How would you rate your overall stress level on a scale of 1-10?

(1= no stress, 10= extremely stressed) Selected Value: 5

Do you have any diagnosed health conditions?

No
Yes

Is there any chance that you are or could become pregnant?

No
Yes

Are you under the care of a physician at this time?

No
Yes

Are you allergic to any medications or herbs?

No
Yes

Are you allergic to any foods?

No
Yes

Have you ever used tobacco or nicotine products?

No
Yes

Have you ever consumed alcohol?

No
Yes

Are you a recovering alcoholic?

No
Yes

Have you ever used cannabis products?

No
Yes

(smoking, vaping oils, CBD, edibles)

How many times per day/week/month do you drink caffeine?

How many times per day/week/month do you drink soft drinks?

How many times per day/week/month do you drink energy drinks?

Please list any other relevant addictions or habits:

Have you experienced a major trauma in any way?

No
Yes

(Physical, emotional, and/or mental)

Do you exercise regularly?

No
Yes

On average, how many hours of sleep do you get per night on weekdays?

when, you other

On average, how many hours of sleep do you get per night on weekends?

Is your sleep disturbed? Do you wake often?

No
Yes

Please list your meds and suppliments:

Name

medication / herb / supplement

Dose

500mg, 1 tsp. etc

Frequency Taken

1/day, as needed, etc.

Prescribed

Prescribed (RX), or Self Care (SC)

Informed Consent

I have read and agree to the Informed Consent and Liability Waiver.

Please list your meds and suppliments:

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