New Client Intake Form Leave this field blank First Name: (Required) Last Name: (Required) Email Address: (Required) Date of Birth: (Required) Address: (Required) Your main residence Mobile No: (Required) Country code + Phone number Occupation: (Required) Doctor's Name & Address: (Required) Please answer all the questions to the best of your ability. As you are going to receive a distance session, Eloise loves to have lots of information on different aspects of your life which may come up in sessions. Marital Status: (Required) Number of Children: (Required) Sexuality: (Required) Gender: (Required) Describe the problem(s) which you are coming to Eloise for. Please include any dates when problems started: If you have sought medical supervision for the above, please give any information: Also, please mention any medical tests you have had in the last year. Past medical history: Any injuries, accidents, surgeries etc and dates... Any medications, supplements, or natural remidies you are taking? Any daily activities you find difficult, or are limited because of your above complaints? Have you ever had this problem before? If so when? Any other healthcare practitioners you are seeing? Or have seen in last 6 months, or planning to see... What are your goals from having a session with Eloise? (Required) Any major lifestyle changes recently? Or in the past? (Required) Please give dates Physical issues: Please mention any issues in each category (leave blank if no problems). Also, mention how frequent the issues are? eg once a month, occasionally, every week, constantly etc Digestive Issues: Acid reflux, constipation, diarrhoea, excessive or no appetite, gall stones, gas, haemorrhoids, heartburn, hernia, cholesterol, indigestion, irritable bowles, nausea, parasites, poor digestion, poor sense of taste, stomach or intestinal pain etc Respiratory Issues: Allergies, asthma, bronchitus, colds, chest tightness, congestion, dry cough, emphysema, hay fever, nasal issues, poor sense of smell, pneumonia, shortness of breath, sinus issues, wet cough, wheezing Cardiovascular Issues: Anemia, angina, blood clots, chest pain, cold hands/feet, dizziness, easily bruised, heart attack, heart disease, heart palpitations, hypertension, hypotension, oedema, poor blood clotting, poor circulation, restlessness, slow heart rate, stroke, sweaty hands/feet Urinary Issues: Cystitus, difficulty or painful urinating, incontinence, kidney infections, kidney stones Nervous System Issues: Dyslexia, developmental or growth issues, epilepsy, head injuries, learning disorders, MS, muscular dystrophy, nervous disorders, numbness, tingling, poor concentration Muscule/Tissue/Bone Issues: Arm or leg weakness, artificial joints, broken or fractured bones, difficulty walking, fascial pain, joint swelling, loss of balance, arthritis (name type), pins, poor circulation, jaw pain, body weakness Muscles & Joint Issues: Please name any body parts which are painful. Please let me know which side L or R. Other head issues: Dental problems, speech issues, swallowing problems, dry eyes, dry mouth, eye pain or problems, headaches, migraines, nose bleeds, hearing issues, Skin Issues: Acne, eczema, psoriasis, shingles, skin conditions, soft or brittle nails Men Only: Impotence, infertility, genital pain, premature ejaculation, problems urinating, prostate problems Women Only: Endometriosis, fibroids, infertility, ovarian cysts, nipple discharge, menapause symptoms, painful periods, heavy flow, PMS, regularity of monthly cycle, painful intercourse. Please also give details of any pregnancies, births & children. Weight gain or loss: Other: Cancer, dizziness, fibromyalgia, herpes, swollen glands, thyroid issues, tremers Pain: Mention any specific areas of pain. Giving a score of 1-10. 1: slight discomfort, 10: you need to go to the hospital Emotional & mental health: Mental Health: Mention any anxiety, chemical dependency, depression, difficulty making plans or decisions, easily angered, obsessive tendencies Please tick any feelings which have persisted in the last few months: Abused Agitated Aggravated Angry Annoyed Anxious Apprehensive Critised Depressed Despair Distress Easily irritated Fearful Grieving Guilty Helpless Hopeless Impatient Intimidated Intolerant Muddled Nervous Outraged Overwhemed Overworked Panic Paralysed Paranoid Persucuted Rejected Restless Sad Unable to grieve Uncertainty Uneasy Worried Other Any comments on feelings above? Family Stress: (Required) None Minimal Moderate Severe Work Stress: (Required) None Minimal Moderate Severe Financial Stress: (Required) None Minimal Moderate Severe Health Stress: (Required) None Minimal Moderate Severe Any comments on above stress factors? Covid: (Required) Have you had Covid? Have you had vaccine? If so which one and give dates. Also let me know your emotional state/feelings on the whole thing. Relaxation & Exercise: (Required) How much time do you have to yourself to relax? Any hobbies? Meditation? Exercise? (What and how often) Sleep: (Required) How restful is your sleep? How many hours do you normally sleep? Life Goals: (Required) Anything you are working towards in life? Anything else? Anything else which doesn't fit on the form which feels relevant or important? Send Save draft
