Client Intake
**EMERGENCY CONTACT***
PHYSICAL Signs & Symptoms*
MENTAL/EMOTIONAL Symptoms?*
What was going on around that time?*
Heart Issues? (HT/CSx)*
Respiratory Issues? (LU)*
Digestive Issues? (ST/SI/LI)*
KIDNEY or LIVER Issues? (KI/LV)*
Hormonal/Body Temperature Regulation Issues? (TW)*
Any current injuries?*
Current MEDICATIONS/SUPPLEMENTS?*
Family History: Paternal*
Family History: Maternal*
Childhood Experience
Current Supplements*
Diet
Hydration
Goals/Desires (SMART)*
How would life be different?*
Support Network & Challenges?*
PRECAUTION: Diabetic?*
PRECAUTION: Cancer Diagnosis?*
PRECAUTION: Pacemaker/Metal implants?*
PRECAUTION: Pregnant/Breastfeeding?*
OTHER NOTES



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