Health Intake Form — Unmasking Healthy Living

Health Intake Questionnaire

Complete your intake form below so we can better understand your health history, current concerns, lifestyle patterns, and wellness goals before your consultation.

Start Intake Questionnaire

Before we meet

This form helps us create a more thoughtful and personalized starting point. Please answer as thoroughly and honestly as you can. Your responses give us insight into symptoms, environment, nutrition, stress, and medical background.

Health Intake Questionnaire

Fields marked with an asterisk are required.

client intake

Basic Information

First Name

Last Name

Phone *

Phone is required

Email *

Email is required

Contact Details

Street Address

City

State

Country

Postal Code

Personal Background

Birth Date

Birth Place

Today's Date

Height

Weight

Gender

Occupation

Referred by

Current Health Concerns

Describe Health Related Problems/Symptoms

What treatments have you tried?

Has anything been successful?

Have you lived or traveled outside of the United States? If so, when and where?

How much time have you lost from work or school in the past year?

Please list any allergies or intolerances (food or environmental)

Medical History

List past Medical and Surgical History

List previous hospitalizations

How often have you taken antibiotics?

How often have you taken oral steroids?

What medications are you taking now? (including birth control/hormones)

List all vitamins, minerals, and other nutritional supplements that you are taking now.

Diet & Digestion

What is your typical daily diet?

How much tea do you consume each week?

How much coffee do you consume each week?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with a particular food or supplement(s)?

How many bowel movements (BM) do you have per day?

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?

Do you have intestinal gas? If so, when?

How many times per week do you drink alcohol?

Exposure & Lifestyle

Do you have mercury amalgam fillings in your teeth? If so, how many?

Do you have any artificial joints or implants? If so, which ones?

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

How would you rate your current level of stress?

Do you exercise regularly? If so, how many times a week?

What type of exercise is it?

Women's Health

Women: If you have a cycle, how long is it and is it regular?

Women: Any other comments related to your cycle? (flow, clots, mood changes, etc.)

Family & Additional Information

Do your parents or siblings have (or had) any health issues? If so, please explain:

Please add any other information you feel is important:

Congratulations, you are on the path to taking your first step towards health and wellness!

Thank you for completing your intake questionnaire. Your answers help us support you with more personalized recommendations and next steps.

Client Signature

Signature

Type your full name to sign

Date Signed

I have read and understand everything on this page. I acknowledge that unmasking healthy living and its associates provide support and do not diagnose, cure, or treat any illness or disease. Furthermore, the undersigned releases unmasking healthy living, its partners, contractors, affiliates, and representatives from any and all liability for any failure to identify or address any medical condition or disease. It is understood and agreed that this is not the purpose of their services.

I have read and understand everything on this page.

Complete the required fields before submitting.