Holistic Therapy Client Intake Form | Ganeden Naturopathic Services

Section 1: General Information

Full Name *Date of Birth *Address *City / State / Zip *Phone Number *Email Address *Work Phone (optional)

Sex

MaleFemalePrefer not to say

Emergency Contact

NamePhone Number

How did you hear about us?

Social MediaInternet SearchReferralOther

Section 2: Medical History

Are you currently taking any medications or supplements?

YesNo

Do you have any allergies?

YesNo

Do you currently have any medical conditions?

YesNo

Are you currently undergoing any treatments?

YesNo

Have you had any surgeries or operations?

YesNo

Section 3: Additional Notes

Please share any additional information about your health history or concerns

Section 4: Consent & Agreement

I have discussed and agree to receive holistic services *I understand these services are not a substitute for medical care *I understand results may vary based on lifestyle and health conditions *I confirm that the information I provided is accurate *

Section 5: Signature

Full Name (typed signature) *Date *