Client Intake Form - Healers Who Share

Name*

DOB

Today's Date

Address

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Email*

Gender

Weight

Height

Occupation

Referred By

Emergency Contact

Relationship

Telephone

Describe Current Conditions/Symptoms

Describe 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 share

What is your goal and intention in pursuing this method of healing?

Health History

Childhood Diseases

Measles
Mumps
Rubella
Chicken Pox
Pneumonia
Whooping Cough
Scarlet Fever
Other

Other

Vaccinations

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 Comments

INFORMED CONSENT AND LIABILITY RELEASE*

I agree to the terms outline here.