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Client Intake Form
Hakomi
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Client Intake Form
(Confidential, for therapist use only)

 

Date: 5/14/2008
Mailing list:

Last name:
First name:
Address:
City:
Province/State:
Country:
Postal code:
Phone:
Home:
Office:
Cellular:
Occupation:
E-mail:  
Emergency contact: Name: Phone:
Birth date:
Age:
Height:
Weight:
Relationship status:
No. of children:
Ages:
Refered by:
Physician: Name: Phone:
Therapist: Name: Phone:

Reason for the visit:
(max. 400 characters)

Start date of symptoms:
Past / present treatments:
(For reason for visit)
(max. 400 characters)
Current medication:
(max. 400 characters)
Supplements:
(max. 400 characters)
Complimentary therapies:
(max. 400 characters)
Eating habits / diet:
(max. 400 characters)

Daily intake: (unit)

Water
 Caffeine
 Alcohol
 Cigarette/Tabaco
Exercise routine:
(max. 400 characters)
Vision:
Glasses / contact lenses:
Smell:
Hearing:
Taste:

Emotional / Psychological
Depression Eating disorder
Mood swings Substance abuse

Explanation (if needed)
(max. 400 characters)
Auto-immune (type)
AIDS / HIV Lymes disease
Allergies Mononucleosis Type
Fatigue Cancer (Type)
Fever (chronic) Herpes (Type)
Fibromyalgia Fungal infections (Type)

Explanation (if needed)
(max. 400 characters)
Endocrine
Adrenal Insufficiency Hyperthyroid
Pituitary dysfunction Hypothyroid

Explanation (if needed)
(max. 400 characters)
Neurological (type)
Epilepsy Insomnia
Dizziness Migraines

Explanation (if needed)
(max. 400 characters)
Musculo-Skeletal
Arthritis Carpal tunnel
Rheumatism Gout Type
Back pain Skin disorder

Explanation (if needed)
(max. 400 characters)
Ear / Nose / Throat
Earaches (Chronic) Jaw pain
Headaches    

Explanation (if needed)
(max. 400 characters)
Cardio-vascular
Angina Hypertension
Heart attack Stroke
Heart failure    

Explanation (if needed)
(max. 400 characters)
Respiratory
Bronchitis Tuberculosis
Pneumonia / Pleurisy    

Explanation (if needed)
(max. 400 characters)
Digestion
Constipation (chronic) Jaundice
Diabetes Liver disorder
Diarrhea (chronic) Ulcers
Gastritis Flattulance
Hepatitis Pancreas
Hypoglycemia    

Explanation (if needed)
(max. 400 characters)
Urinary
Bladder infection Kidney stones

Explanation (if needed)
(max. 400 characters)
Reproductive
Sexually Trans. Disease (type) Miscarriages (#)
Endometriosis Type Abortion (#)
Pregnancies (# & C)    

Explanation (if needed)
(max. 400 characters)
Major Illnesses
Chicken pox Mumps
Measles Whooping cough
German measles Scarlet Fever

Explanation (if needed)
(max. 400 characters)
Others

Explanation (if needed)
(max. 400 characters)

Please list any injuries you had and have presently :
(max. 400 characters)

Please list any surgeries you had or know you will have :
(max. 400 characters)
Please list any traumatic, or life treatening events that
occurred in your life, and when they happened :

(Ex.: Separation, divorce, depression,
deaths or other significant event)
(max. 400 characters)
What do you hope for and what are your expectations
from this healing today and long-term :
(max. 400 characters)
What is your connection with spirituality:

(religious background, current practice, development)
(max. 400 characters)
Brothers / Sisters :
Rank in family :
Relationship with mother
As a child
(max. 400 characters)
Present
(max. 400 characters)
Relationship with father
As a child
(max. 400 characters)
Present
(max. 400 characters)
General

(Further details on reason for visit or anything else you want to share or want me to know)
(max. 400 characters)

Important
If you have problems filling our form, we invite you to download
and fill the printable PDF document. Thank you.

Click here to download the PDF version (233 Ko)