Client Intake Form Fill out the form below and submit online or click here to download/print as a PDF and submit via snail mail. If you choose to mail your documents, please be sure to include Intake Form, Consent Form with photo to: PO Box 501, Fairfield CT 06824. Name* DOB MM slash DD slash YYYY Today's Date MM slash DD slash YYYY Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneEmail* Gender Weight Height Occupation Referred By Emergency Contact Relationship TelephoneDescribe Current Conditions/SymptomsDescribe how your problem(s) started. What was happening in your life before symptoms manifested?Describe a typical day in your life – how and where you spend your time and with whom you spend it. How do you generally feel about your day to day routine? Please elaborate on any aspect that comes up for you that feels right to shareWhat is your goal and intention in pursuing this method of healing?Health HistoryChildhood Diseases Measles Mumps Rubella Chicken Pox Pneumonia Whooping Cough Scarlet Fever Other Other Vaccinations MMR DPT POLIO CHICKEN POX TB Rotavirus HIB Hepatitis HPV Flu Menningococcal Pneumococcal Other Other Please list previous injuries and/or surgeries Please list current medications and purpose Please list any diagnoses and/or diseases Please list habits that concern you Describe your exercise or fitness routine Describe your sleep pattern Describe your digestion and any special diets or restrictions Allergies, Sensitivities or Intolerances? Such as to foods, sound, touch, etc.. Major Health Problems of blood relatives on maternal and paternal sides (mother, father, grandparents, aunts, uncles and siblings)If you are writing for your child, please share what you can about your pregnancy experience – what your stressors were, medications taken, what was going well and what you felt wasn’t going well. Also share what you can about your labor and delivery experience.Additional CommentsINFORMED CONSENT AND LIABILITY RELEASE* I agree to the terms outline here.