Initial Intake Form

First name

Last name

Phone

Do you accept text messages?

Yes

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Referral source

Emergency contact - Name & Phone

Please identify your main health concern

When did this start?

How did this start?

What makes it better?

What makes it worse?

What other treatments have you tried?

How much does this affect your daily life?

Please identify any additional health concerns

Past Medical History:

Illnesses

Surgeries

Significant Trauma:

i.e. motor vehicle accidents, fractures, life events, etc.)

Do have a history of current or past infectious disease? If yes, please describe.

Medicines

please list all medications, herbs, vitamins and over the counter drugs)

Allergies/Sensitivities

Any foods, drugs, medicines or environmental factors you're sensitive or allergic to