Client Intake Form

Welcome! This form helps us understand your wellness goals and how we can best support you. All responses are confidential and used solely for your care. Please respond as simply or as thoroughly as you like.

Personal Information:

First name

Last name

Birthday

Month

Day

Year

Blood type:

Gender:

Referred by:

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Health & Wellness Goals:

What are your top health goals or concerns?

Please list any diagnoses and/or allergies:

Please list all prescription medications and/or herbal supplements you are currently taking:

How long since last antibiotic?

Please list any surgical procedures:

Out of the above symptoms, which would you most like to focus on today?

Nutrition & Lifestyle

What does a typical day of meals look like for you?

How much water are you drinking per day? Where does your water usually come from?

What other beverages do you consume on a regular basis?

How is your sleep?

Do you get regular movement/exercise? If so, what type and how often? Are these activities you enjoy?

On a scale from 1-5, how would you describe your current stress level? 1=low stress, 5=extreme stress

What are some things you feel most stressed about?

What are some hobbies/activities you enjoy? How much time per week are you able to spend doing those activities?

Herbal & Holistic Preferences

Have you taken herbal supplements before?

Yes

Are you open to trying new holistic practices or suggestions?

Yes

Nutritional Client Statement:

I fully understand that staff members at the House of Sunshine are not medical doctors or licensed healthcare practitioners. They do not diagnose or treat disease and I am not here to receive a medical diagnosis or treatment procedures. The services performed are at all times for the purpose of educationally supporting general wellness and nutritional health. They do not include include the diagnosis, treatment or prescription of remedies for any medical condition. I recognize that I have the constitutional right to make informed decisions about my own health. No one at the House of Sunshine has advised me to discontinue any medical treatment or care recommended by my licensed medical provider. If I choose to deviate from medical advice, I do so voluntarily and accept full responsibility for my choices and their outcomes. I agree to release and hold harmless the House of Sunshine and its staff from any liability or consequences related to my personal decisions. I also confirm that I am attending this consultation-and any future visits of my own free will, I am not acting as an agent for any local, state, or federal agency or on behalf of any regulatory or investigative body. By choosing to participate in these services, I affirm that I am taking personal responsibility for my health and well-being, and I understand the scope and limitations of the support offered.

I have read and agree to the above statement.

Check additional boxes to authorize:

I authorize the practitioners at the House of Sunshine to perform a muscle response health analysis and provide an herbal suggestion program for me. These suggestions are not to diagnose or treat any disease and are for educational purposes only.

I understand that if I choose to cancel a scheduled appointment with a practitioner I must do so with a 24 hour notice or I may be subject to a cancellation fee.

Signature

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Date

Month

Day

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