CLIENT INTAKE FORM

 
Print this form and fill it before you visit Maala A Jhaam for a healing session.
 

Name:                                                                                          Date:

Email :                                                                               Occupation :

Address:

Height :                  Weight :                                           Date of Birth :

Phone Home :                                                 Phone Work :                            

Emergency Contact (name & phone):

Relationship Status:                      # Children :              Ages :                   

   Referred by :

Physician (name & phone):

Therapist (name & phone) :

Reason for Visit (add details on back if necessary) :               

   Date of Onset :

Current/Previous Treatment (for reason for visit) :

Current Medications :

Current Complementary Therapies/Supplements :

Eating Habits/Diet :

Amount Daily Intake:
Water:                  Caffeine:                  Alcohol:                    Cigarette/Tobacco:

Exercise routine :

Vision:- Wear glasses/contacts             Smell:             Hearing:                   Taste:

 

Please mark the following areas of disease or symptoms as “C” – current, “P” - past, “O”– occasional and “CH” - chronic.Explain if necessary.

EMOTIONAL / PSYCHOLOGICAL

NEUROLOGICAL(type)

RESPIRATORY

REPRODUCTIVE

Depression

 

Epilepsy

 

Bronchitis

 

Sexually Trans.Disease (type)

 

Eating disorder

 

Dizziness

 

Pneumonia/Pleurisy

 

 

 

Mood swings

 

Insomnia

 

Tuberculosis

 

 

 

Substance abuse

 

Migraines

 

DIGESTION

 

Endometriosis

 

AUTO-IMMUNE (type)

 

MUSCULO-SKELETAL

 

Constipation (chronic)

 

Pregnancies (# & C if current)

 

AIDS/HIV

 

Arthritis

 

Diabetes

 

Miscarriages (#)

 

Allergies

 

Rheumatism

 

Diarrhea (chronic)

 

Abortion (#)

 

Cancer (type)

 

Back Pain

 

Gastritis

 

MAJOR ILLNESSES

 

Fatigue

 

Carpal Tunnel

 

Hepatitis

 

Chicken Pox

 

Fever (chronic)

 

Gout

 

Hypoglycemia

 

Measles

 

Fibromyalgia

 

Skin Disorder (type)

 

Jaundice

 

German Measles

 

Fungal Infections (type)

 

EAR/NOSE/THROAT

 

Liver Disorder

 

Mumps

 

Herpes (type)

 

Earaches (chronic)

 

Ulcers

 

Whooping Cough

 

Lyme Disease

 

Headaches

 

Flatulence

 

Rheumatic Fever

 

Mononucleosis

 

Jaw Pain

 

Pancreas

 

Scarlet Fever

 

ENDOCRINE

 

CARDIO-VASCULAR

 

URINARY

 

OTHERS

 

Adrenal Insufficiency

 

Angina

 

Bladder Infection

 

 

 

Pituitary Dysfunction

 

Heart Attack

 

Kidney Stones

 

 

 

Hyperthyroid

 

Heart Failure

 

 

 

 

 

Hypothyroid

 

Hypertension

 

 

 

 

 

 

 

Stroke

 

 

 

 

 

 
  • Please list any injuries you had and have:

 

  • Please list any surgeries you have had or know you will have:

 

  • Please list any traumatic, or life threatening events that occurred in your life, and when they happened: (ex. Separation, divorce, deaths, depressions or other significant event) :

 

  • What do you hope for and what are your expectations from this healing today and long-term:

 

  • Is there anything else you want to share or want me to know?