Health Intake Form

Please complete this form prior to working together.

General Information

Name

First Name

Last Name

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Before we begin, I would like to hear about some of your greatest accomplishments.

Anything you are proud of: degrees, publications, specializations, family, spiritual practices, travel, financial investments, professional accomplishments.

What are you passionate about?

What lights you up?

NOW, LET US GET TO IT

Current Weight

Target Weight

If different than above

Please list emotional, physical, medical symptoms, diagnosis or challenges here.

Medications & Supplements

Please describe your medical history.

What is important for me to know?

Do you take any medications?

If so, please list out and length of time you have been using the medication

Do you take any supplements?

If so, please write the manufacturer name and how long you have been taking.

Checkbox

Have you ever utilized energy medicine or kinesiology to test your supplements?

YES!

No, but interested to incorporate this

No idea what you are talking about!

Diet

What does your typical diet look like?

What primary liquids do you consume and how much?

Coffee, tea, water, juice, alcohol, etc.

How many fruits and vegetables do you get in a day?

Are these cooked, steamed, raw?

Where do you get your protein from?

How often do you have a bowel movement?

What is the consistency: hard, soft, easy to go, hard to go?

Detox Questions

Have you ever tried cleanses, detoxes or changed eating habits? If yes, please describe

Lifestyle

What are your first thoughts when you open your eyes?

Are you slow or fast to get out of bed?

Do you wish this was any different?

What does your morning routine currently look like?

No judgment here!

What does your ideal morning look like?

What are your daily routines like?

What does your evening routine look like prior to bed?

What time do you typically get ready for bed?

What time do you fall asleep?

Is your sleep restful?

How do you know if it is or isn't?

What exercise/movement do you love to do?

Mindset

What are the positive or negative recurring thoughts that continue to occupy your mind?

Again, no judgment!

Please describe any traumatizing events in your life that may influence you today.

In my experience, emotional health and financial health can be closely linked regarding abundance or scarcity mindset. What is your perspective on finances & money?

Do you have a spiritual practice?

If so, what does it look like?

Human Design & Astrology

What is your familiarity with incorporating your astrology or human design as a guide towards optimal health?

No idea what you’re talking about

Only a small amount and want to use this more

Use it to guide each day already

If you know your human design, or astrological signs for your sun / moon please add details here.

To what extent do you incorporate astrology or human design as a part of your healing journey and creation for what you desire?

None

Little

A Significant Amount

LAST QUESTIONS!

Primary Goal

What is one primary goal that if it was resolved would greatly affect your life.

Secondary Goal

What is a secondary goal that would greatly affect your life.

Anything else to share?