FOLLOW UP INTAKE FORM
Please complete the following intake form and send it back to me at least 24 hours before our first session so that I can best help you reach your goals :)
Date*
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First Name*
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Last Name*
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PLEASE CHOOSE THE ANSWER THAT BEST APPLIES BELOW...
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Sleep (consider hours, bedtime, sleep quality, interruptions, etc.)*
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Stress (work and home)*
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Activity Levels (exercise, cleaning, walking, shopping, etc.)*
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Nutrition (eating nutritious foods and avoiding junk foods)*
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Digestion (completeness, frequency, color, odor, gas, belching)*
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Energy (morning, afternoon, evening)*
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Mental Outlook and Positive Attitude*
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Relationships (work and home)*
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Socializing, Pursuing a Hobby, Volunteering*
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Mental Clarity and Focus*
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Motivation and Completion of Tasks*
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Spiritual Fulfillment and Journey*
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Pain (frequency, tolerance, management, etc)*
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PLEASE PROVIDE MORE DETAILS BELOW
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What is your most dominant complaint?*
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Please list any other current complaints here.*
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What differences have you experienced since our last session (positive or negative)?*
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Is there anything else you want me to know?
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