Client intake form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="04c785a3.jpg"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>Welcome</B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE="Welcome"><U><B>home</B></U></A></div> <div> <A HREF="id130.htm" TARGET="_top" TITLE="Informed consent form"><U>Informed consent form</U></A>   |   <B>Client intake form</B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="04dd2b03.jpg"> <div> Health Kinesiology Forms</div> <div> Print, fill out, and bring with you to your first appointment.</div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Client intake form</I></div> <bR> <div> <B>Nutritional Profile and Client Intake Form</B></div> <bR> <div>                                              Email: ______________________________</div> <bR> <div> Name _______________________________________________ Age ____________ Date ________________</div> <bR> <div> Phones (Home) _____________________ (Work) ______________________ (Cell) _____________________</div> <bR> <div> Address __________________________________________________________________________________</div> <bR> <div> Had any surgery? ______ (Describe) ___________________________________________________________</div> <bR> <div> Medical traumas? ______ (Describe)    __________________________________________________________</div> <bR> <div> Psychological traumas? ______ (Describe) _______________________________________________________</div> <bR> <div> Taking any medication? (Also in the past) _______________________________________________________</div> <bR> <div> Vaccination history _________________________________________________________________________</div> <bR> <div> Dental history (Filling materials) ______________ (Teeth pulled) ___________ (Root Canals)______________</div> <bR> <div> On birth control pill? __________</div> <bR> <div> Nutritional supplement? ______ How long? ____________ (Describe) ________________________________</div> <div> _________________________________________________________________________________________</div> <bR> <div> Taking drugs? (Cocaine, H, marijuana, pills, etc.) _________________________________________________</div> <bR> <div> Smoke? ______ (Quantity) __________________________ How long? ______________________________</div> <bR> <div> Use alcohol? ______ (Quantity) __________________________ Past habit? ___________________________</div> <bR> <div> Drink coffee? ______ (Quantity) ___________________ Milk? ________ (Quantity) ____________________</div> <bR> <div> Like sweets? _______ In what form? ___________________________________________________________</div> <bR> <div> Nervous? __________ Depressed? ___________ Under stress? ______________________________________</div> <bR> <div> Eat beef? _______ (Frequency) _____________________ Pork? ________ (Frequency) __________________</div> <bR> <div> Typical breakfast (Describe) __________________________________________________________________</div> <bR> <div> Typical lunch (Describe) _____________________________________________________________________</div> <bR> <div> Typical dinner (Describe) ____________________________________________________________________</div> <bR> <div> Snacks? _______ When? ______________ (Describe) _____________________________________________</div> <bR> <div> Estimated percentage of uncooked food daily? ____________________________________________________</div> <bR> <div> How many glasses water daily? ________ Purified or tap? __________________________________________</div> <bR> <div> Sleep well? _______ Usually how long? ________________________ Naps? ___________________________</div> <bR> <div> Do you exercise? _______ How many times weekly? _____________ How long? _______________________</div> <bR> <div> Is your job physical? ________________________________________________________________________</div> <bR> <div> How often do your bowels eliminate? ___________________________________________________________</div> <bR> <div> Any numbness of hands or feet? ________________________ Leg aches or cramps? _____________________</div> <bR> <div> Been to a Doctor lately? ________________ Reason? ____________________________________ Diagnosis? __________________________________________________________________________________________</div> <bR> <div> Other concerns: ____________________________________________________________________________</div> <div> __________________________________________________________________________________________</div> <div> __________________________________________________________________________________________</div> <div> __________________________________________________________________________________________</div> <bR> <div> On a scale of 1-10, 10 being the very best, how do you rate your energy level? __________________________</div> <bR> <div> Briefly state why you have come to this session. __________________________________________________</div> <div> _________________________________________________________________________________________</div> <div> _________________________________________________________________________________________</div> <bR> <div> Any other information about your history you need to share. (Family, Job, Other social concerns, Hopes, Dreams, Goals) ____________________________________________________________________________</div> <div> __________________________________________________________________________________________</div> <div> _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.</div> <bR> </td> </tr></table></body>