Patient Health Intake Questionnaire

Section 1 — Personal Information

Full Name *

Date of Birth *

Age

Sex *

Pronouns (optional)

Marital Status

Height

Weight

BMI

Enter height & weight

Phone *

Email

Occupation

Home Address

Preferred Contact Method

Best Time to Contact

Emergency Contact Name

Relationship

Emergency Phone

Section 2 — Reason for Visit

Primary Health Concern *

How long have you had this concern?

Is it constant or intermittent?

What makes it better?

What makes it worse?

Severity (1 = minimal, 10 = severe) 5/10

What have you tried so far?

What are your health goals?

Section 3 — Current Health Conditions

Check all that apply and note date of diagnosis below.

Dates of diagnosis / additional notes

Primary Care Physician

Specialist(s) Currently Seeing

Date of Last Physical Exam

Date of Last Blood Work

Do you have recent lab results to share?

Section 4 — Family Health History

Check all conditions that apply to immediate family members and note the affected relative(s).

Condition	Affected Relative(s)
Heart Disease / Coronary Artery Disease
Stroke or TIA
High Blood Pressure (Hypertension)
Type 2 Diabetes / Insulin Resistance
Type 1 Diabetes
Cancer (any type)
Autoimmune Disease (lupus, RA, MS, Hashimoto's)
Thyroid Disorders
Obesity / Metabolic Syndrome
Mental Health Conditions (depression, anxiety, bipolar)
Dementia / Alzheimer's Disease
Neurological Conditions
Osteoporosis / Bone Disease
Kidney Disease
Liver Disease
GI / Digestive Disorders (Crohn's, colitis, IBS)

Additional Family History Notes

Section 5 — Medical History

Previous Surgeries (with approximate dates)

Previous Hospitalizations

Significant Injuries or Accidents

Previous Diagnoses No Longer Active

Have you ever had a blood transfusion?

Have you ever had a serious infection (e.g. sepsis, meningitis)?

Additional Medical History Notes

Section 6 — Current Medications

List all prescription medications you are currently taking.

Medication	Dose	Frequency	Prescribing Dr	Reason	How Long

Do you have any known drug allergies or adverse reactions?

If yes, please list drug(s) and reaction(s)

Section 7 — Current Supplements & Vitamins

List all supplements, vitamins, herbs, and over-the-counter products you currently take.

Supplement / Vitamin	Dose	Frequency	Brand (optional)	Reason / Goal

Do you take any herbal or traditional remedies?

If yes, please list them

Do you take any hormone-related supplements (e.g. DHEA, pregnenolone, melatonin)?

If yes, please list them

Additional Supplement Notes

Section 8 — Allergies & Sensitivities

List all known allergies and sensitivities, including reactions experienced.

Medication & Supplement Allergies

List any medications or supplements that have caused allergic reactions

Have you ever had anaphylaxis (severe allergic reaction)?

Do you carry an EpiPen?

Additional Allergy / Sensitivity Notes

Section 9 — Diet & Nutrition

Help us understand your current eating patterns and nutritional habits.

How many meals do you eat per day?

How often do you eat out or order takeout?

Daily water intake

Daily caffeine intake

Daily sugar / processed food intake

Describe a typical day of eating (breakfast, lunch, dinner, snacks)

Do you experience cravings?

Do you experience bloating or discomfort after eating?

Additional Diet / Nutrition Notes

Section 10 — Lifestyle & Habits

Physical Activity

How often do you exercise?

Primary type of exercise

Average session duration

Any physical limitations or injuries affecting exercise?

Sleep

Average hours of sleep per night

Sleep quality

Typical bedtime

Sleep concerns or patterns (describe)

Tobacco, Alcohol & Substances

Tobacco / Nicotine use

If former/current, how long / how much?

Alcohol consumption

Recreational drug use

Additional substance use notes

Stress & Mental Wellbeing

Current overall stress level

Primary sources of stress

Do you currently see a therapist or counselor?

Stress management practices

Additional Lifestyle Notes

Section 11 — Women's Health

Complete this section if you identify as female or have female reproductive anatomy. Skip if not applicable.

Menstrual History

Age at first period (menarche)

Current menstrual status

Average cycle length

Average period duration

Flow heaviness

Date of last menstrual period (LMP)

Do you experience PMS or PMDD?

Do you experience painful periods (dysmenorrhea)?

Menstrual symptoms or concerns (describe)

Reproductive & Pregnancy History

Number of pregnancies

Number of live births

Number of miscarriages / losses

Are you currently pregnant?

Are you breastfeeding?

Are you trying to conceive?

Type of birth control currently used

How long have you used current birth control?

Reproductive history notes (complications, fertility treatments, etc.)

Section 12 — Men's Health

Complete this section if you identify as male or have male reproductive anatomy. Skip if not applicable.

Prostate & Urological Health

Date of last prostate exam / PSA test

Last PSA result

Urinary symptoms (describe)

Sexual & Reproductive Health

Do you have concerns about sexual function or performance?

Fertility concerns?

Additional Men's Health Notes

Section 13 — Mental Health & Emotional Wellbeing

Your mental and emotional health is an integral part of your overall wellness. Please answer as openly as you feel comfortable.

Trauma & Life Events

Have you experienced significant trauma or adverse life events?

Have you experienced grief or significant loss?

Please describe any trauma or life events you feel comfortable sharing

Substance Use & Mental Health

Do you use alcohol or substances to manage emotional distress?

Have you ever sought help for substance use?

Safety & Crisis

In the past 12 months, have you had thoughts of harming yourself or others?

Have you ever attempted suicide?

If you are in crisis, please call or text 988 (Suicide & Crisis Lifeline) or go to your nearest emergency room.

Section 15 — Goals, Expectations & Consent to Care

Help us understand what you hope to achieve and how we can best support you.

Health Goals & Priorities

What are your top 3 health goals for working with us?

What does optimal health look like for you?

What has prevented you from reaching your health goals in the past?

How motivated are you to make lifestyle changes right now?

How soon are you hoping to see results?

Care Preferences

What type of support is most important to you?

How do you prefer to receive information?

How involved do you want to be in your care decisions?

Do you have any concerns about working with a holistic practitioner?

Please describe any concerns or questions you have before we begin

Referral & Communication

How did you hear about us?

If referred, who referred you?

Have you worked with a holistic or functional medicine practitioner before?

If yes, what worked or didn't work?

Consent & Acknowledgment

By completing this intake form, I acknowledge that the information I have provided is accurate and complete to the best of my knowledge. I understand that this information will be used to support my care and will be kept confidential in accordance with applicable privacy laws. I understand that holistic and integrative health services are not a substitute for emergency medical care, and I agree to seek emergency services if needed.

I have read and agree to the above acknowledgment.

Patient / Client Signature (type full name)

Date

If completing on behalf of a minor, guardian name

Relationship to patient

Any final notes or anything else you'd like us to know?

Section 16 — HIPAA Notice & Privacy Acknowledgment

Your Privacy Rights Under HIPAA
Holistic Healing LLC is committed to protecting the privacy of your health information. Under the Health Insurance Portability and Accountability Act (HIPAA), you have the following rights:

Right to Access: You may request a copy of your health records at any time.
Right to Amend: You may request corrections to your health information if you believe it is inaccurate or incomplete.
Right to Restrict: You may request restrictions on how we use or disclose your health information.
Right to Confidential Communications: You may request that we contact you in a specific way or at a specific location.
Right to an Accounting of Disclosures: You may request a list of instances where we have disclosed your health information.
Right to a Paper Copy: You may request a paper copy of our Notice of Privacy Practices at any time.

How We Use Your Information
Your health information may be used for treatment, payment, and healthcare operations. We will not share your information with third parties without your written authorization, except as required by law (e.g., public health reporting, court orders, or emergencies involving imminent harm).

Telehealth & Electronic Communications
If you communicate with us via email, text, or online forms, please be aware that these methods may not be fully secure. By using these methods, you acknowledge and accept the associated privacy risks.

Patient Acknowledgment & Authorization

I have been offered the opportunity to review the Notice of Privacy Practices for Holistic Healing LLC and understand how my health information may be used and disclosed. I authorize Holistic Healing LLC to use and disclose my protected health information as described above for the purposes of treatment, payment, and healthcare operations. I understand that I may revoke this authorization at any time in writing, except where action has already been taken in reliance on it. I consent to receive communications from Holistic Healing LLC via email, phone, or text regarding my care, appointments, and health information.

Full Name (Signature)

Date

If signing on behalf of a minor or incapacitated individual, your name

Relationship

For questions about your privacy rights, contact us at info@holistichealingllc.us — Holistic Healing LLC — holistichealingllc.us

Country/Region