Client Intake Form

Client Information

Date

Name

Email

Sex

Address

City

State

Zip

Home Phone

Home Phone :: 719-xxx-xxxx

Other Phone

Other Phone :: 719-xxx-xxxx

Date of Birth

Date of Birth :: month/day/year

Age

Height

Height :: in feet and inches

Weight

Weight :: in lbs

Referred by:

Reasons and Expectations

What is the primary reason for your visit?

How long has this been a concern?

Have you sought previous guidance and/or treatment to address your concerns? If yes, please explain briefly

Any other complaints or concerns you would like to address?

What are your expectations and/or goals for our session?

Personal Details

Where were you born? (city/state/country)

Where did you grow up?

How long have you lived in your current city/state?

With whom do you share your home? Please list number of household members, relationships, and ages:

Animal companions? If so, what kinds and how many?

Who Is the primary caregiver in your household? (if you, write “Self”)

Who does the majority of the shopping and food preparation in your household?

Occupation

Avg. hours/day and hours/week?

Please briefly describe your work environment in terms of stress levels, physical/sedentary, social/isolated, chemical use, air quality, travel, daytime breaks, vacations/holidays, or anything you think may be relevant to our work together:

Ethnicity

Religion

Clubs/Memberships

Education

Please mark the highest level that applies:

high school
associate degree
technical/trade school
bachelors degree
masters/doctorate
other (please explain)

In what year did you complete your most recent coursework?

Exercise

Do you spend time outdoors, and if so, how frequently and in what activity?

Do you exercise?

Yes
No

If yes, please list types of exercise, duration, and frequency (ex: yoga 1.5 hours/3 xwk)

Please list any other hobbies or activities you enjoy

Sleep Patterns

When do you typically go to sleep?

Rise?

Do you wake up at all or often once you have gone to sleep?

Do you have difficulty going to sleep or staying asleep?

Yes
No
Don't know

Difficulty waking up?

Yes
No
Don't know

How do you feel when you wake up?

Do you notice your energy slump during the day?

Yes
No
Don't Know

If so, when?

Food and Eating Habits

Please take a moment to describe a typical or frequent…

Breakfast:

Lunch:

Snack:

Dinner:

Dessert:

Craving:

What foods do you tend to eat for comfort?

What foods do you tend to eat when you are stressed?

Sad?

Happy?

Angry?

On average, how many glasses water do you consume per day?

Tap
Purified
Other

If you live with others, do you dine together? How often?

On average, how many meals/week do you cook?

Eat out?

Do you enjoy cooking?

Yes
No
Don't know

Do you enjoy eating out?

Yes
No
Don't know

Where do you tend to eat your meals?

Do you perform or engage in other activities while eating? (watch tv, read, drive, etc)? If so, which activities/meals?

Favorite restaurant/type of food when dining out:

On average, how many meals do you eat each day?

On average how many snacks?

What is your favorite meal of the day?

Have you followed a diet program before?

Yes
No
Don't know

If yes, what diet and how do you feel it worked for you?

Do you currently follow a specific diet?

Yes
No

If yes, any of these?

Are there any foods you avoid, and if so, for what reason?

Do you feel like you have a strong, adequate, or weak support system to help you make lifestyle changes?

Strong Support System
Adequate Support System
Weak Support System

Who/what offers you the most support?

Medical/Health History

Have you ever had an eating disorder?

Yes
No
Not sure

Please describe:

Have you gained or lost weight recently?

Yes
No
Not sure

If yes, how much and over what time period?

Are you currently under any other health professional’s care for any conditions, illnesses, etc? If so, please explain and list the name of the physician/professional:

Are you currently taking any prescription medications? If yes, please list below (separate by commas if more than one):

Medication

Medication :: Ex: Lipitor

Reason

Reason :: Ex: High Cholesterol

Year Started

Year Started :: Ex: 1999

Dosage

Dosage :: Ex: 10 mg/day

Do you have any allergies (food, medical, environmental)?

Do you use caffeine?

Yes
No
Very rare

If yes, what forms and how much per day?

Do you smoke or use chewing tobacco (past or present)?

Yes
No

From what age?

How frequent and how much tobacco do you use?

How many alcoholic drinks do you consume? (per day, week, or month)

How many times per year do you have dental cleanings/exams?

Rarely
Once a year
2 times a year
3-7 times a year
More that 7 times a year

Do you have any silver amalgam dental fillings?

Yes
No
Not sure

What is your blood type?

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Client Intake Form