IHP Client Intake Form

"*" indicates required fields

Welcome! This intake form is designed to give us a complete picture of your health and lifestyle so we can best support you on your journey to feeling your absolute best. It’s detailed for a reason—every piece of information helps us create a plan that’s tailored to you. Take your time, be honest, and know that there’s no “perfect” answer—just what’s true for you. Your responses are completely confidential and will only be used to support your health and well-being. You’re taking an incredible step toward better health, and we’re here to guide and empower you every step of the way. You’ve got this!

Date*

MM slash DD slash YYYY

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Birth Date*

MM slash DD slash YYYY

Place of Birth*

Gender*

Height*

Weight*

Occupation*

Referred by:

Describe Problem/Symptom(s): (Be as detailed as needed)*

What treatments have you tried?*

Has anything been successful?*

What goal do you hope to achieve working together?*

Do you live alone?*

Yes

Do you have any pets or farm animals?

Yes

Have you lived or traveled outside of the United States?*

Yes

If yes, when and where?

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

Yes

If yes, please describe:

Have you experienced any major losses in life?*

Yes

If yes, please describe:

How much time have you lost from work or school in the past year?*

What do you do for work?*

Did you feel safe growing up?*

Yes

Please share more, if desired.

Have you been involved in abusive relationships?*

Yes

Pleas share more, if desired.

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?*

Yes

Please share more, if desired.

Do you feel safe, respected and valued in your current relationship?*

Yes

Please share more, if desired.

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?*

Yes

Please share more, if desired.

Briefly list past medical and surgical history:*

Any previous hospitalizations?*

Yes

If yes, please describe here:

How often have you taken antibiotics?*

How often have you taken oral steroids?*

Please list current medications with dosages:*

Please list all vitamins, minerals, and other nutritional supplements you are taking:*

Were you (select all that apply):*

A full term baby?

Preemie?

Breast fed?

Bottle Fed?

Not sure

As a child, did you eat a lot of sugar and/or candy?*

Yes

Please share more, if desired.

What is your typical daily diet (what did you eat yesterday & today)?*

Are you on a special diet?*

Do you consume the following on a daily basis?*

Tea

Coffee

Soda

Other Caffeine

Dairy

Cheese

Bread

Sugar

Candy/Chocolate

Dessert

Please provide more detail, if desired.

Please list anything special about your diet we should know (if nothing, state N/A):*

Do you have symptoms immediately after eating, such as bloating, belching, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement?*

Do you feel much worse when you eat certain foods?*

Yes

Not Sure

If yes, please describe.

Do you feel much better when you eat certain foods?*

Yes

Not Sure

If yes, please describe.

Does skipping a meal affect your symptoms?*

Yes

Not Sure

If yes, please describe.

What time(s) do you typically eat? Please share breakfast, lunch, dinner and snack times.*

Have you ever had a food that you craved or really 'binged' on over a period of time?*

Do you have an aversion to certain foods? If yes, what foods?*

How many bowel movements (BM) do you have per day?*

Do you have any of the following?*

Constipation

Diarrhea (loose stool)

If yes, please describe.

Do you have intestinal gas? If so, when?*

How many times per week do you drink alcohol? And, what is your drink of choice?*

Have you ever used recreational drugs?*

Yes

If yes, please share more if comfortable doing so.

Have you ever used tobacco? (If so, for how long?)*

Are you exposed to second-hand smoke regularly?*

Yes

Do you have mercury amalgam fillings in your teeth? If so, how many?*

Do you have any artificial joints or implants? If so, please describe.*

Do you feel worse at certain times of the year? Please describe more, if applicable.*

Have you, to your knowledge, been exposed to toxic metals in your job or at home?*

Yes

Do odors affect you?*

Yes

If yes, please describe:

How would you rate your current level of stress?*

Have you ever had psychotherapy or counseling?*

Yes

Are you currently, or have you ever been married?*

Yes

Please list your hobbies and leisure activities:*

Do you exercise regularly?*

Yes

If yes, how many days per week?*

0-1

2-3

4-5

6 or more

I don’t exercise

What type(s) of exercise do you do?*

Do your parents or siblings have (or had) any health issues?*

Yes

If yes, please describe:

Why do you believe you would be a good candidate to work with Angelique?*

Congratulations! You are on the path to taking your first step towards health, wellness, and vitality!*

By checking this box I agree to the following:

I have read and understand everything on this page. I acknowledge Angelique Swann and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Stephen Cabral, his lab partners, his independent representatives associates, and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.

Signature (your name submitted below will be considered your electronic signature):*

First Last

Date submitted:*

MM slash DD slash YYYY

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