New Patient Intake Form Patient Information - Name * First Name Last Name Pronouns Birthdate * Phone Number * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Would you like to be added to my email list for occasional updates and offerings? * Yes please No thanks What is your occupation, or how do you spend most of your time? What is your intention or goal in working with me? How would you describe your current lifestyle? Do you have any health concerns and/or are you currently under medical care for any reason? Please check anything that is a part of your health history. anxiety asthma/respiratory issues autoimmune condition or chronic illness cancer circulatory/heart issues depression grief headaches/migraines major dental work, surgeries, or accidents medication/use of supplements sleep issues or fatigue stress trauma other Please describe any of the above areas you marked. Is there anything else that would be helpful for me to know before your appointment? Thank you!I look forward to working with you soon. Please contact me with any questions you have.
