NEW MEMBER FORM CLIENT INTAKE QUESTIONNAIRE Personal Information * First Name Last Name Date of Birth * MM DD YYYY Age * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * First Name Last Name Emergency Contact Phone # * (###) ### #### Health & Medical History Do you have any existing medical conditions? (e.g., diabetes, hypertension, heart disease, etc.) * Yes (please specify) No Are you currently taking any medications or supplements? * Yes (Please specify) No Do you have any allergies? (e.g., food, medications, environmental) * Yes (please specify) No Have you had any surgeries or hospitalizations in the past 5 years? * Yes (Please Specify) No Do you have any physical injuries, chronic pain, or mobility limitations? * Yes (please specify) No Have you been under the care of a healthcare provider for any mental health conditions (e.g., anxiety, depression, stress management)? * Yes (optional details) No Lifestyle & Wellness Goals What are your primary wellness goals? (Check all that apply) * Stress management Weight management Increased energy levels Improved sleep quality Pain relief Fitness improvement Emotional well-being Other: How would you describe your current stress level? * Low Moderate High How many hours of sleep do you get on average per night? * Less than 5 5-6 7-8 More than 8 Do you follow any specific dietary plan or restrictions? * Vegetarian/Vegan Gluten-Free Keto/Paleo No restrictions Other How often do you engage in physical activity? * Rarely/Never 1-2 times per week 3-4 times per week 5+ times per week Wellness Services Interest What services are you interested in? (Check all that apply) * Health Testing Nutritional IV Therapy Photobiomodulation Frequency Specific Microcurrent Ozone Nutritional Counseling Other: Have you received any of these services before? * Yes (please specify) No Are you open to recommendations for additional wellness services? * Yes No Additional Information Do you have any preferences or concerns regarding your wellness experience? How did you hear about our wellness center? Referral Website Social Media Other Is there anything else we should know to better assist you? Consent & Agreement I certify that the information provided is accurate and complete to the best of my knowledge. I understand that wellness services are not a substitute for medical care and that I should consult my healthcare provider for any medical concerns. Date * MM DD YYYY Name * First Name Last Name Please check your email for Member Welcome Information and next steps.
