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Client Intake Form
Step
1
of
2
- INITIAL CLIENT QUESTIONNAIRE
50%
NAME:
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Title:
Given Name:
Surname:
DATE OF BIRTH:
DD slash MM slash YYYY
AGE:
MALE / FEMALE:
MALE
FEMALE
ADDRESS:
Street Address
Address Line 2
City
State
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
TELEPHONE:
(Home):
(Work):
(Mobile):
EMAIL:
Enter Email
Confirm Email
MARITAL STATUS:
Single
Married
De-facto
Divorced
Separated
Widowed
SPOUSE NAME:
First
Last
SPOUSE AGE:
CHILDREN GENDER & AGE:
GENDER
AGE
OCCUPATION:
EMERGENCY CONTACT:
PHONE:
FAMILY DOCTOR:
PHONE:
REFERRED BY:
Family
Friend
Internet Search
Local Newspaper
Clinic Signage
Other
HEALTH CONCERNS
Please list the primary health concerns you are seeking treatment for.
HEALTH CONCERN
YEAR SYMPTOMS FIRST NOTICED
PREVIOUS MEDICAL HISTORY
Please list any significant illnesses or operations that you have had in the past.
ILLNESS
OPERATION
YEAR
Have you had a flu injection this year?
Yes
No
MEDICATIONS
Please list all prescribed drugs and/or supplements that you are currently taking including dosage.
PRESCRIPTION MEDICATION
SUPPLEMENT
DOSAGE PER DAY
REASON FOR TAKING
ALLERGIES / INTOLERANCES
Dairy
Tomatoes
Eggs
Soy
Artificial Flavours
Dust Mites
Yeast
Artificial Colours
Medications
Wheat
Salicylates
Cigarette Smoke
Gluten
Shellfish / Fish
Pollens
Peanuts
Metals (Jewellery)
Cat Fur
Sugars
Alcohol
Cleaning Products
FAMILY HISTORY
Age (if living)
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
General Health (G=Good, P=Poor)
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Please tick ‘√’, if any of the following conditions are relevant to your family.
Alcoholism
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Anaemia
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Asthma/Hayfever
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Cancer
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Cystic Fibrosis
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Diabetes
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Epilepsy
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Heart Disease
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
High Blood Pressure
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Kidney Disease
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Mental Illness/Depression
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Osteoarthritis
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Rheumatoid Arthritis
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Stroke
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Thyroid Condition
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Cause of Death
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
Age (at death)
MOTHER
FATHER
SISTER
BROTHER
G/MOTHER MATERNAL
G/FATHER MATERNAL
G/MOTHER PATERNAL
G/FATHER PATERNAL
LIFESTYLE PROFILE
Please state number of units and select frequency of use:
Alcohol (mls)
Day
Week
Month
Soft Drinks (Reg-mls)
Day
Week
Month
Antacids
Day
Week
Month
Soft Drinks (Diet)
Day
Week
Month
Cigarettes
Day
Week
Month
Sugar (Added)
Day
Week
Month
Coffee
Day
Week
Month
Tea
Day
Week
Month
Takeaway
Day
Week
Month
Water
Day
Week
Month
Pain Relief
Day
Week
Month
Computer (hrs)
Day
Week
Month
Recreational Drugs
Day
Week
Month
TV (hrs)
Day
Week
Month
Do you exercise?
TYPE OF EXERCISE
HOW OFTEN
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