Cafe of Life Kalispell
115 Commons Way Suite 201
Kalispell, MT 59901
(563) 370-7626
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 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
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                                       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!
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