Client Intake Form | Sydney Ryan Integrative Health

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Today's Date

Month

Day

Year

Age

Height

Weight

Emergency Contact Name

Emergency Contact Number

Primary Care Physician (if applicable):

Physician Phone:

How did you hear about this practice?

Biological Sex

Male

Female

Please list your top health concerns in order of importance

When did these concerns begin?

Have you previously sought treatment for these concerns and was anything helpful? Please explain.

Have you lived or traveled outside the United States?

Yes

No

If yes, where and when?

Have you or your family recently experienced any major life changes?

Have you or your family recently experienced any major losses in life?

Surgeries or hospitalizations in the last 5 years? Please explain.

Please list any medications you are currently taking. Name of the medication, dose and reason.

Please list any supplements you are currently taking. (including vitamins, minerals, herbs, etc.)

Do you have any mercury amalgam fillings in your teeth?

Yes

No

How often have you taken antibiotics?

Does your family have a history of health issues? If yes, please explain.

Food Allergies:

Medication Allergies:

Environmental Allergies:

Occupation:

Average Stress Level (1-5):

Hours of sleep per night:

Do you feel well rested upon waking?

Yes

No

Sometimes

List some of your hobbies and leisure activities:

How many days of the week do you exercise?

What kind of exercise?

How would you describe your typical diet?

Daily caffeine intake:

Daily water intake:

Do you consume alcohol?

Yes

No

Sometimes

If so, how many days per week?

Do you smoke or use tobacco?

Yes

No

Sometimes

If so, how long?

Are you exposed to secondhand smoke regularly?

Yes

No

Have you ever used recreational drugs?

Yes

No

Age of first menstruation (if applicable) :

Are your cycles regular?

Yes

No

Date of last menstrual period:

Have you used hormonal birth control?

Yes

No

If yes, how long:

If yes, please explain:

Have you previously completed functional or specialty lab testing?

Yes

No

If yes, please explain:

What would you most like to achieve through your work with this practice?

Anything else you would like the practitioner to know?

I certify that the information provided is accurate and complete to the best of my knowledge. I have read and understand everything on this page. I acknowledge Sydney Ryan is a natural health practitioner and does NOT diagnose, cure or treat any illness.

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Sydney Ryan Integrative Health LLC