Please download this form by clicking on the link below, then print it, sign it and bring it to your first session. Thank you!
| adult_intake_form__1_.odt |
About You
Name__________________________________________________________________________________
Address _______________________________________________________________________________
City ______________________________State _________________ Zip __________________________
Phone (home) _________________________________ (work) _________________________________
Cell phone __________________________________ email ____________________________________
Birthdate ________/________/________ Occupation_______________________________________
Marital Status: (circle one) married single divorced partner separated widowed
Do you have children? How many? ______ Names and ages if under 18: _____________________
_______________________________________________________________________________________________
Whom may we thank for referring you to the Café of Life, or, how did you hear about us? _______________________________________________________________________________________________
Reasons for seeking service at the Café of Life: _________________________________________________
When did you last see a Chiropractor? ____________________ Dr. ________________________________
What are your hobbies or interests? ___________________________________________________________
Subluxation, or nerve interference, is caused by physical, chemical, and emotional stress.
Please answer these questions as best as you are able:
Physical stress
Have you had any accidents, falls, or traumas? Please describe: ________________________
Have you had any surgeries? Please describe: __________________________________________
Have you been diagnosed with any illness or disease? Please describe: __________________
Birth trauma often causes the first subluxation. Was your own birth a difficult one?
Please describe: ________________________________________________________________________
Is your body subjected to stressful repetitive activities at home or at work
(keyboarding, painting, crossing legs, sitting, driving, carrying children, etc)? ___________________________________________________________________________
What sports or exercise do you participate in? _________________________________________
Do you regularly practice yoga, stretching or another form of movement to increase your flexibility? _____________________________________________________________________________
What is your level of physical activity? Low _________Moderate ___________High __________
Chemical Stress
Do you eat a balanced diet? Circle your intake of: (Z=Zero, L=Low, M=Med, H=High)
Meat/Protein Fruits Vegetables Breads/Grains Dairy Products Oils/Fats
Z L M H Z L M H Z L M H Z L M H Z L M H Z L M H
Do you use the following chemicals?
Sugar Pop Coffee Tea Alcohol Tobacco
Z L M H Z L M H Z L M H Z L M H Z L M H Z L M H
Do you take any medications or drugs? Which ones, and for how long? _________________
Are you allergic to anything? __________________________________________________________
Is your air and water pure? Yes ______ No _______
If not, please describe: _______________________________________________________________
Emotional Stress
What is the level of stress in your life in these areas? (Low (L), Medium (M), High (H))
Home _______ School _______ Work _______ Relationships ________ Children _______
Family ________ Friends ________ Loss of loved one _________ Divorce _________
Separation _________ Finances _______ Health _______
Do you have a spiritual practice? ______________________________________________________
Write the one word you would use to describe yourself: _________________________________
What is your level of commitment to yourself, your life, your health and your well-being?
Low _____________________ Medium _____________________ High _________________________
Is there anything else I should know about you? _______________________________________
_______________________________________________________________________________________
Thank you for allowing me to serve you!
