Client Intake Form

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Your contact information:
 
Full name:
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Email address:
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Address:





Phone:
Date of Birth:

Gender:

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Male
Female
 
Please check any health issues that apply and add comments as indicated in the "Comments" section.
 
 
Allergies (specify in comments)
Anxiety/Stress (describe)
Blood pressure (indicate high or low)
Depression
Diabetes
Digestive problems (specify)
Fatigue
Headache
Insomnia
Irregular periods (describe)
Menopause
Migraines
Muscle or joint pain (describe)
PMS
Pregnant (# months?)
Respiratory problems (specify)
Skin condition (describe)
Skin sensitivity
Thyroid condition (specify)
Varicose veins
 

What three adjectives describe your current mental / emotional state?

Comments or other medical conditions:
 
Other:
 

Main focus of the blend should be?

Under a dr.'s care?

Other considerations?

Yes
No
 
 
 
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