Intake Form

Full Name (Legal and Chosen)

Age and Preffered Pronoun

Where are you located?

Let's start with the fun stuff. Tell me about your life at the moment. What are your hobbies? Do you work? Have kids? Pets?

Tell Me about your health related history. Any major illnesses, diagnoses, or surgeries?

If you are a person who menstruates please tell a bit about your cycle. Mood? Pain? Regularity?

Tell me a bit about your immediate families health history.

What are your current health goals?

Are you taking any prescription medications? Please list them here.

Are you taking any herbal supplements or vitamins? Please list them here.

Tell me a bit about your relationship with food. Do you have any food allergies, preferences, or dietary restrictions?

Do you drink caffeine regularly? What kind and how much daily?

Do you have a history of tobacco use?

Do you have a relationship with alcohol? Please tell me about it.

Are you physically active? What kind of activity do you enjoy? How often?

Tell me about your sleep history. Do you fall asleep easily? Do you stay asleep or frequently wake?

Tell me about your healthcare team. Do you have a primary care physician? Are you seeing an acupuncturist? A therapist?

Anything else I should know?

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Note: Please fill out the fields marked with an asterisk.