Holistic Preventive Clinic
Online Client Intake Form


We are happy to help you with any part of your healing program. By submitting this intake form, you are setting your intention to have a phone consultation with one of the Holistic Preventive Clinic staff, at a charge of $1.60 per minute.

** IMPORTANT: Please ensure that you have a stable internet connection when completing this form, especially if you will invest time in providing detailed responses. (A partially completed form cannot be saved.)

The Holistic Preventive Clinic respects the privacy of its clients. All personal information provided on this form will be held in strict confidence and will not be released to any third party without prior written authorization.


Name:


E-mail:


Phone:

** IMPORTANT: We require either your e-mail or phone number above in order to be able to contact you!

Street:


City:
     
State:
     
ZIP:



Date of Birth:


Occupation:


Weight:
     
Height:
     
Blood Type:



Blood Pressure:
     
Cholesterol Levels:


** IF POSSIBLE, please also e-mail us a complete blood count (CBC) test from your medical doctor.


How many times per day do your bowels move?


Health challenges you struggle with:



Check all of the following challenges you have now or have had in the past:

Arthritis     
 Bad Breath     
 Bloating/Gas     
 Chemical Sensitivities


 Cold Hands/Feet     
 Colon Problems     
 Depression     
 Fatigue


 Frequent Colds/Flu     
 Headaches     
 Heartburn     
 Heart Palpitations


 Hemorrhoids     
 Irritability     
 Low Blood Sugar     
 Nausea


 PMS     
 Rectal Itching     
 Sinus Infections     
 Swollen Glands


 Teeth Grinding     
 Urinary Infections



How did you hear about the Holistic Preventive Clinic?



Health benefits you are looking for:



Describe any of the following:

Addictive struggles:


Joint/muscle aches and pains:


History of antibiotic use:


Cortisone-type drug:


Rash/eczema/skin problems:


Surgery:


Allergies/asthma:


Food cravings:


Yeast problems:


Intestinal troubles:


Blood/mucus in stools:


Perceived brain and mind health (history of TBI or concussions):


Health of your eyes:


Health of your nervous system:




Therapies you've tried for any of the problems listed above:




Foods you eat in an average 48-hour period:

Breakfast:


Lunch:


Dinner:


Snacks:




Exercise regimen (type and frequency):


Describe your adolescence in a few words:


Exposure to toxins:


Daily water consumption:


Other liquids consumed:


How often do you cook for yourself?


What oils do you include in your diet?


List all of the vitamins, minerals, supplements and herbs you are taking:


List all of the over-the-counter and prescription medications that you currently take:


What are the major stresses in your life and how do you deal with them?


Are you highly knowledgeable about your inner microbiome?


List any history with enemas and/or suppositories:



Check all of the health challenges you would like help with:

Diet     
 Deep Tissue Cleansing     
 Fertility Issues     
 Fasting


 Addiction     
 Weight Loss     
 Weight Gain     
 Other (describe below)




Are you interesting in writing as a health tool?

Are you interested in a mindfulness course?


IMPORTANT: Check here if you will be contacting us via SKYPE  >>


IMPORTANT: Check the box below if you will be contacting us via SKYPE.