Client Intake
Questionnaire


  • Life In General

  • You have a magic wand! List three things about yourself or your life that you’d change.
  • What three symptoms are most bothersome to you right now?

  • An Average Day

  • Let’s start with when do you wake up? What do you do first?
  • What do you usually do throughout the day?
  • What do you do in the evening?
  • Do you have any daily habits? (Tobacco, alcohol, caffeine, other)
  • Prescribed Medications:
  • Daily Supplements:
  • What time do you usually go to bed?
  • How long does it take to fall asleep?
  • How often do you wake up and why?
  • Rate your sleep from 1 - 10 (1 is poor, 10 is great)
  • How soon after you wake do you have your first food?
  • How many times do you eat during the day?
  • Do you have any dietary restrictions ie lactose intolerance or gluten sensitivity. You will have the opportunity to add more detail in the Food Questionnaire.
  • On average how many times a week do you eat out?
  • Are you physically active during the day?
  • Do you have any formal exercise program?
  • Are you wanting to add more movement to your daily routine?
  • Rate your stress from 1 - 10? (1 is low, 10 is high)
  • What are your main sources of stress?
  • What helps you relax? Ie. exercise, meditation, the outdoors
  • When was the last time you felt well? When did symptoms begin & have they changed?

  • Let’s start right at the beginning - your beginning

  • Do you know if you were a cesarian or vaginal birth?
  • Were you a breast-fed baby?
  • Were there any points in your life when antibiotics were prescribed and for what reason ie ongoing infections ie Strep Throat
  • Any life events that caused major stress? Ie divorce, illness