New Client Intake Form

Please complete the confidential health history form as thoroughly as possible, filling out all applicable sections based on your personal health history. The more detail you provide, the better we can understand your needs and support you effectively. If you have any questions or need assistance while completing the form, please don’t hesitate to ask—we’re here to help.

This is a judgment-free space—please share openly and honestly on this assessment. Cravings, food challenges, and eating habits can sometimes point to underlying imbalances in the body, many of which can be supported and corrected.

This form can not be saved with progress. Please allow yourself 30 - 45 minutes to complete this assessment.

Personal Information

First Name *

Last Name *

Email *

Phone Number *

Address *

Age *

Date of Birth *

Current Weight *

Height *

If minor name(s) of Parents/Guardians

In case of emergency notify (name) *

Phone *

Family Doctor

May we contact them?

Phone

Person Responsible for Payment *

Address *

Phone *

What are your major health concerns and intentions for contacting us?

Please list any current health conditions diagnosed by a medical doctor.

Have you had any bloodwork or exams within the last 2 months?

Please list all herbs, vitamins, and dietary supplements you are currently taking. Include dosage and frequency.

List all medications you are currently taking indicating whether they are over the counter or prescription. Include dosage and frequency.

List all medications, herbs, foods, environmental factors, to which you have a known allergy.

Please list any cravings you may have and time of day these occur - ex sugar or sweet foods after main meals, salt, breads, cookies mid-afternoon.

Please select if you currently or have utilized any of the following:

Aluminum pots, cookware, foil, deodorants and toothpaste containing aluminum.
Have or had mercury fillings in your teeth.
Have or do use a lot of soy foods or soy-based milks.
Have or had older carpets, wall to wall carpets.
Used pesticides, weed killers or harsh chemicals.
Prepare food in a microwave oven.
Wear synthetic materials.
Experience sensitivity to perfumes or other chemical odors.

Dietary Information

Describe below your typical meals. Please be as specific as possible. For example, instead of "oil" note the type of oil used. Instead of "bread" list the type of bread. Instead of "vegetables" list the type of vegetable, how prepared, canned, frozen or fresh. Please include all beverages, type and quantity.

Breakfast:

Morning Snack(s):

Lunch:

Afternoon Snack(s):

Dinner:

Amount of water consumed daily (number of glasses per day):

Any reccuring food cravings, such as salt, starch, sugar, chocolate, etc. Please list as many as applicable including time of day or month:

Family History

Please describe any relevant or major health related issues to the individuals below (cancer, mental illness, diabetes, heart disease, etc.)

Mother

Father

Sister(s):

Brother(s):

Maternal Grandparents:

Paternal Grandparents:

Medical History

List all major health problems including any operations. Note problem and year.

Please use this space to add any other information about yourself that you think will be helpful.

By completing this health intake form, you acknowledge that you are providing your personal and health information voluntarily. All information submitted is confidential and will be handled solely within the PMA (Private Members Association). You understand that the PMA and its practitioners respect your right to choose natural health and healing options. By submitting this form, you agree to these terms and affirm the accuracy of the information provided.

I agree to the terms and conditions

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Regression Therapy

Regression Therapy

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