The Retreat Client Intake Form
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2The Retreat Client Intake Form
PERSONAL PROFILE
Name
Date of Birth
Street Address
Day Phone
City
State
Zip
Eve Phone
Occupation
Email
MEDICAL PROFILE
Are you currently under the care of a health care practitioner? Yes
No
If yes, please specify:
List current medications/vitamins/herbs:
Injuries/accidents/illnesses/surgeries still affecting you:
Please mark any of the following that you now have or have had:
Musculoskeletal
Circulatory
Respiratory
__Bone/Joint Disease
__Heart Condition
__Asthma/Difficulty Breathing
__Tendonitis/Bursitis
__Phlebitis/Vericose Veins
__Emphysema
__Arthritis/Gout
__Blood Clots
__Sinus Problems
__Jaw Pain (TMJ)
__High/Low Blood Pressure
__Allergies, specify
__Lupus
__Lymphedema
__Other:
__Spinal Problems
__Thrombosis/Embolism
__Other:
__Other:
Skin
Nervous System
Reproductive
__Allergies, specify
__Shingles
__Pregnant, # of weeks
__Rash
__Numbness/tingling
__Ovarian/Menstrual Problems
__Athletes Foot
__Pinched Nerve
__Prostate Problems
__Herpes/Cold Sores
__Other:
__Other:
__Eczema/Psoriasis
Other:
Other
__Migraines/Headaches
__Anxiety/Depression
Additional Client Remarks/Comments:
__Diabetes
__Chronic Pain/Fatigue
__Sleep Disorder
__Cancer/Tumors
__Contagious Diseases
__Contact Lenses
__Tobacco use
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