4yhealth intake questionnaire

As an Integrative Health Practitioner, I look at all the facets of someone’s life, past and present, that could have affected their health. As such, you may find this intake form a lot longer, and a lot more personal than any you have completed in the past. This helps me develop a more complete picture of your health far beyond what you would experience at a typical doctor’s appointment. Please try to answer all questions to the best of your knowledge and ability. I appreciate you taking the time to do this. Remember, no detail is unimportant :)

The form must be completed a minimum of 24 hours before your scheduled appointment.

Which service have you invested in? *
Name *
Name
Today's Date *
Today's Date
Please register for Skype if you do not have an account. If not possible please specify below.
Date of Birth *
Date of Birth
0 being the lowest, 10 the highest. Think of you work/life balance, your relationships, current health concerns...
0 the lowest (can barely move), 10 the highest (boundless energy, always wired)
How much sleep do you get per night on average? *
Did you feel safe growing up? *
Have you been involved in abusive relationships in your life? *
Do you feel safe, respected and valued in your current relationship? *
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *
Please ignore the line below and answer after each of the items listed below
How many bowel movements (BM) do you have per day on average? *
Have you ever had psychotherapy or counseling? *
I have read and understand everything on this page. I acknowledge Ryan Barby does not diagnose, cure, or treat any illness or disease. Further, by checking the "I Agree" button below I release Ryan Barby 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. *
Waiver

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

* All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.