Intake form | Holistic Health

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Intake Form

First name*

Last name*

Date of birth

Phone

Email*

What is your primary reason for this session and/or your health?

Physical Body and Mental Health

Your Body

Massage and bodywork

Tight shoulders

Neck

Back lower, mid , upper

Hips

Legs

Feet

Tendons

Ligaments

Muscles

Fascia tightness

Anything that wasn't in selection or Anything you would like to add.

Energy

Mostly low

Stable

Mostly high

Fluctuates either high or low

If you are in pain, how long have you been in pain for and what is the severity?

Do you have any diagnosed medical conditions, injuries, or surgeries?

Anything that wasn't in selection or Anything you would like to add.

Nutrition

Select any system that has an issue

Respiratory system

Blood pressure and circulatory

Skeletal system

Muscular system

Nervous system

Digestive system

Kidneys and urinary

Immune system

Lymphatic system

Endocrine system

Healing the body with food and supplementation

How to cook and plan weekly diet

Wellness program: Cleanse and Rejuvenate

Are you currently taking any medications or supplements?

Anything that wasn't in selection or Anything you would like to add.

Exercise

Yoga Restorative

Qi-gong and Tai chi

Strength training and Postural Alignment

Mental Health

Are you interested in Nervous system regulation, help for P.T.S.D, or would like to learn more about meditation

How is your sleep quality

Depression

Burn out

Grief/loss

Trauma/Abuse

Addiction

Childhood wounds

Emotional overwhelm

Stress and Anxiety

Hormonal Imbalance

Life Transitions

Anything else you would like to share in regards to your situation

What are you hoping to experience or achieve through our work together?

Visit Preference

Drop-In

Monthly visit - membership rewards

Wellness Program - Multi-session personalized plan

Final Thoughts. Any questions or concerns before our first appointment?

CONSENT STATEMENT

"I confirm that the information provided is accurate and I consent to receiving holistic health and wellness services from Human Nature. I understand these services are complementary in nature and do not replace conventional medical care."

I agree to the above statement

Reserve your appointment for a free consultation

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