Client Intake Form

ADVERTISEMENT

Client Intake Form
Name ________________________________________ Home # __________________ Cell # _________________
Address ______________________________________________________________________________________
Birth date ____________________________ Occupation _______________________________________________
Marital status _________________________ Children? ____________ Ages _______________________________
Last visit to primary physician? _________________________ Why? _____________________________________
Blood pressure reading _________/__________ Name of Primary Care Physician ___________________________
Date of last physical exam? _______________________ Height ________________ Weight __________________
How is your general health? ______________________________________________________________________
Diagnosis (if any) from your doctor ________________________________________________________________
Reason for today's visit? _________________________________________________________________________
General stress level
(no stress)
(manageable stress)
(unmanageable stress)
Comments ____________________________________________________________________________________
Exercise regularly? ⃝ Yes ⃝ No
Frequency _____________________________________________________
Do you smoke?
⃝ Yes ⃝ No
Frequency _____________________________________________________
Consume caffeine? ⃝ Yes ⃝ No
Frequency _____________________________________________________
(Caffeine refers to coffee, tea, soft drinks, or any other caffeinated beverages)
Consume diet soft drinks? ⃝ Yes ⃝ No
Frequency _______________________________________________
Consume alcohol?
⃝ Yes ⃝ No
Frequency _____________________________________________________
Eating habits
(typical consumption on a normal day):
Breakfast _____________________________________________________________________________________
Mid-Morning Snack _____________________________________________________________________________
Lunch ________________________________________________________________________________________
Afternoon Snack _______________________________________________________________________________
Dinner ________________________________________________________________________________________
Bedtime Snack _________________________________________________________________________________
3
Enhancements Aromatherapy LLC
Client Intake Form

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 4