Client Intake Form Page 2
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4Type of food normally eaten
(indicate if seldom, moderately or heavily consumed):
Meat
S M H
Fish
S M H
Eggs
S M H
Cheese S M H
Milk
S M H
White Bread S M H
Raw Vegetables S M H
Fresh Fruits S M H
Potatoes S M H
Cooked Grains S M H
Fried Foods S M H
Chocolate S M H
Refined Sugar Products S M H
Malt S M H
Caramel S M H
Sweet Foods S M H
Salty Foods S M H
Medical History
Surgeries/Serious Illness/Accident? ____________________________________ When? _____________________
Please describe what procedure(s) followed and when _________________________________________________
_____________________________________________________________________________________________
Nature of Injuries _______________________________________________________________________________
Do you experience headaches?
N
Y
Frequency? ___________ Migraines? N Y Frequency? __________
What do you believe to be the cause of your headaches or migraines? ____________________________________
Average # hours of sleep? _________ Do you wake up at night? Y N If yes, how often? _____________________
How much time do you spend outdoors? ________________________ Doing what? _________________________
Activity level: ⃝ Sedentary ⃝ Moderate ⃝ Very active
Time spent using a computer/video games each day ___________________ When? ________________________
Stomach or digestive complaints? _________________________________________________________________
Reproductive/urinary complaints? ________________________________________________________________
Other conditions you have been diagnosed with _____________________________________________________
_____________________________________________________________________________________________
What vitamins or supplements are you taking? _______________________________________________________
_____________________________________________________________________________________________
What medications (prescriptions) are you taking and for what condition(s)?
Medication/Dosage/Frequency _________________________________________ Reason ____________________
Medication/Dosage/Frequency _________________________________________ Reason ____________________
Medication/Dosage/Frequency _________________________________________ Reason ____________________
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Enhancements Aromatherapy LLC
Client Intake Form
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