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Sandra ChabotIntake Form - Sandra Chabot

Pre-Consultation Intake Form

When it comes to our health, we all need a little bit of guidance from time to time. Your body is a highly complex entity that requires a total mind-body-spirit connection in order to reach its peak performance.

No matter where you are on this new health journey, a little bit of TLC can go a long way. When your inner goods are given the nourishment they need to heal, what can only be described as magic begins to unfold.

Thank you for choosing me as your guide!

By the way – everything on these sheets stays between us. I only ask questions I believe are relevant in helping you to feel your best again.

xx Sandra

Let’s get started!!!

CONTACT INFORMATION

 

ALL ABOUT YOU

 

FUN STUFF

 

HEALTH CONCERNS

  • Please list your TOP three health concerns (e.g. digestion, energy level, stress):

  • Please list your TOP three main symptoms (e.g. bloating, fatigue, chest pain):

 

PERSONAL HEALTH HISTORY

  • List all medications you are currently taking along with the tart date, dosage, and reason for use:

  • List all medications you were previously taking along with end date, dosage, and reason for use:

 

FAMILY HEALTH HISTORY

 

DIET

 

DRINKS

 

SLEEP

 

POOP (please don’t be shy, I live for this stuff)

 

LIFESTYLE

 

FITNESS

 

STRESS

 

Fieldset

 

Verification

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