Intake Form
Welcome to A Total Health For Life!  We ask clients visiting us for the first time to answer some questions about their health, health related history, and basic information. The answers will help us work with you on your journey towards well-being.
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Basic Information
Name: *
Date of Birth *
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Place of Birth
What is your gender identity?
Home Phone Number
Office Phone Number
Cell Phone Number
Best Email Address
Home Address
Marital Status:
Clear selection
Do you have any children? If so what are their ages?
Emergency Contact
Name, Phone Number, and Relationship to the Client
Date of First Visit
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How did you hear about us?
Is this your first experience with Body Work, Stretch Therapy, Personal Training or Neurokinetic Therapy? *
Doctor's Information
Date of Last Physical Exam:
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Name of Primary Doctor:
Address of Primary Doctor:
Phone Number of Primary Doctor
Vital Signs
If you cannot take a new measurement, just write down the most recent one you remember.
Body Weight
Body Height
Blood Pressure
Pulse per Minute
Respiratory Rate per Minute
Average Body Temperature
Chief Complaint
Please be as detailed as possible
What is your primary goal for this visit?
Where are you experiencing discomfort? *
When did this instance of discomfort start?
What do you believe caused this instance of discomfort?
When does it bother you the most? *
On a scale of 0-10 (10 being the most severe) what is the severity of the discomfort you are experiencing?
Does anything make it worse?
Does anything make it better?
Has this discomfort ever affected you in the past? If so when and how?
Did you go to see a doctor for this issue?
Did the doctor provide a diagnosis, or test result including a blood test, x-ray,  etc.
Other
Diagnostic and Symptom Related Information
Please select any issues or symptoms that you experience:
Cardiovascular Symptoms
Muscle and Joint Related Symptoms
Gastrointestinal Symptoms
Neurological Symptoms
Men's Health Symptoms
Women's Health Symptoms
Dental Symptoms
Ear Symptoms
Nose, Throat, and Mouth Symptoms
Eye Symptoms
Skin and Hair Symptoms
Head and Neck Symptoms
Respiratory Symptoms
Which emotions do you feel most often?
If possible please describe more about the emotions you picked:
What are the major causes that influence your mental status?
Where does tension center in your body?
How do you de-stress or relax?
Do you often grind your teeth or chew gum?
Other
Perspiration
Do you sweat easily?
When do you sweat?
Where do you sweat the most? :
If your sweating pattern is different from the past, what is the difference and when did it start?
Sleep Schedule and Issues
How many hours do you normally sleep per night?
When do you usually go to bed?
When do you usually wake up?
Do you have difficulty with any of the following:
How many times do you wake up per night?
If applicable, when did you start to wake up from your sleep during the night?
What time do you usually wake up during the night?
Do you fall back to sleep easily?
Do you take sleeping pills to address any of the issues mentioned above? If so, how frequently?
Have you been diagnosed with sleep apnea?
If your sleep is different from the past, when did it change, and what do you think caused it?
Other
Bowel Movements
How frequently do you have bowel movements during the day?
Do you go at a regular fixed time during the day? If so, when?
Is it easy or hard for you to go?
Is incontinence or diarrhea a problem?
Is constipation or difficulty having bowel movements a problem?
Do you have hemorrhoids?
Is anal itching or burning a problem for you?
My bowel movement:
Do you need laxatives, and if so when did you start using them?
If your bowel movements are different from the past, when did the change happen and what do you believe caused it?
Is their anything which makes your symptoms related to bowel movements better or worse?
Urination
How frequently do you urinate during the day?
What is generally the color of your urine?
Do you have the urgency to go?
Can you void completely or do you experience dripping?
Do you have trouble starting to urinate?
Do you experience dripping when you sneeze?
Do you tend to hold your urination?
Do you wake up at night due to the urge to urinate?
Do you experience burning when you urinate?
Has your urine ever been cloudy, greasy, or had debris in it?
Have you ever had blood in your urine?
Have you ever had urinary tract stones? If so when?
Other
Libido
How is your libido (sex drive?)
If your sex drive is different from the past, what are the differences and when did they begin?
Other
Energy Level
How are your energy levels?
Do you fatigue easily?
What time of day is your energy the highest?
What time of day is your energy the lowest?
Other
Temperature Preference and Bleeding
Do you more often feel cold or hot?
Are your hands and/or feet cold?
For women only: Do you have hot flashes?
Do you prefer warm or cool temperatures in a room/outside?
Which season do you like the most?
Do you bleed or bruise easily?
Other
Lifestyle Information
How frequently do you exercise and what is the general duration each time.
What kind of exercise do you usually do?
Do you sweat when  exercising?
Describe your diet and briefly list the food you had for dinner last night:
Do you feel thirsty?
What beverage do you drink the most?
How much water do you drink a day? (Not including other drinks, soup, tea etc.) (1 fluid ounce = 29.6 cc=1/8 cup)
What is your occupation? (can be more than one)
How long have you been working on this job?
How many hours do you work per week?
What is the worst part of your job?
What is the best part of your job?
If you are not working now, when did you stop, and why?
Do you have any hobbies?
What activity occupies your time the most beside your job?
Medical History
Have you ever experienced or been diagnosed with any of the following issues?
Can you describe your past or current medical diagnosis in more detail?
Have you been hospitalized or required major tests or procedures including operations, chemical exposures, blood transfusions etc.?
Type of operation or illness, Date, Name of Hospital, City, State
Have you ever severely sprained an ankle or broken a bone?
Have you ever been in a car accident? Please describe the accident and when it occurred.
Have you ever had a major fall?
Have you ever received acupuncture treatment? (skip if doesn`t apply)
When, frequency, and for how long? For what? By who? Does it help?
Have you ever received herbal treatment? (skip if doesn`t apply)
When, frequency, and for how long? For what? By whom? What were you prescribed and did it help?
Have you ever received massage treatment?(skip if doesn`t apply)
When, frequency, and for how long? For what? By whom? Does it help?
Have you ever received homeopathic treatment? (skip if doesn`t apply)
When, frequency, and for how long? For what? By whom? Does it help?
Have you ever received ayurveda treatment? (skip if doesn`t apply)
When, frequency, and for how long? For what? By whom? Do the treatment help?
Have you ever received any other alternative treatment? (skip if doesn`t apply)
When, frequency, and for how long? For what? By whom? Did it help?
Have you ever received any psychotherapy? (skip if doesn`t apply)
When, frequency, and for how long? For what? By whom? Did it help?
Medications, Supplements and Drugs
Do you take any of the following over the counter medications:
How frequently do you use over the counter medications?
Please list any prescription medications you are taking (skip if doesn`t apply)
Name of medication, dosage/day, reason for taking, taking since?
Please list any prescription supplements you are taking: (Skip if doesn`t apply)
Name of supplement, dosage/day, reason for taking, taking since?
Other Commonly Used Substances
Have you ever consumed caffeinated beverages?
If so which ones and how often, what age did you start or stop, and is it a problem for you?
Have you ever smoked cigarettes (tobacco?)
If so how much and how often do you smoke, what age did you start or stop, and is it ever a problem for you?
Have you ever drunk alcohol?
If so how much and how often do you drink, what age did you start or stop, and is it ever a problem for you?
Have you ever used Marijuana?
If so how much and how often do you use it, what age did you start or stop, and is it ever a problem for you?
Have you ever used drugs for recreational purposes?
If so how much and how often do you use them, what age did you start or stop, and is it ever a problem for you?
Other
Allergies
Medication Allergies
Please list the medications you are allergic to and what happens when you take them.
Other Allergies
Family Medical History
Allergy
Blood disorder/anemia
High blood pressure
Heart disease
Stroke
Seizures
Diabetes
Endocrine disease
What type of endocrine disease does the family member have?
Musculoskeletal disorder
Kidney or bladder disease
Stomach or intestinal disease
Substance abuse
Skin disease
Mental illness
Tuberculosis
Herpes oral/genital
HIV
Hepatitis
Sexually transmitted disease: syphilis/gonorrhea/chlamydia/genital warts
Alzheimer`s Disease
Cancer or tumor
Other
Women's Health Issues (skip if doesn`t apply)
How old were you when you first experienced menstruation?
What is the length of your menstruation cycle?
How many days does your period last?
What color is the flow?
Is your flow usually heavy or light, or somewhere in between? Are there any clots?
Do you ever bleed between your periods?
Do you experience any premenstrual symptoms, and if so what are they?
Do you experience any symptoms during your period and if so what are they?
Have you experienced changes in your menstrual pattern and if so when did they begin?
Including  the amount, duration, spotting etc.
Do you experience vaginal discharge? If so please describe it.
Do you use contraception? If so which kind?
Do you experience menopause?
If so, do you experience any symptoms during menopause?
Are you currently pregnant?
Are you presently trying to get pregnant?
Are you currently breast feeding?
How many times have you been pregnant?
Other Women Health Issues
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