Intake Form | Mindful Objective

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Health Intake Questionnaire

A health intake questionnaire is essential for understanding a client’s overall health, lifestyle, and goals to tailor personalized, effective wellness strategies.

Your Journey to Wellness Starts Here!

* required to be answered.

Today's Date

First Name

Last Name

Phone Number

Address

State

Zip Code

Gender

Marital Status

Date of Birth

Your Age Range

Occupation

Referral (if you were referred by someone, let us know so we can thank them)

Health

Do you have a Primary Care Provider? If yes, who is your primary care provider?

What is the reason for today's visit? Please include when any problems began?

What have you tried to improve any above problems?

Height

Weight

Allergies to Medications?

If yes to medication allergies, please explain in detail.

Allergies to Food?

If yes to food allergies, please explain in detail.

Surgical History? Include dates if you recall.

Hospitalizations? (For what? How long? Include dates if you recall.)

Do you currently have any health conditions?

Current Medications and Supplements including condition you take them for:

Do you currently exercise?

If so, explain your exercise program.

Do you smoke?

Do you drink alcohol?

Context of Care

What are some of your short and long-term goals in working with our practice?

What behaviors or lifestyle habits do you currently engage in regularly that you believe contribute to and support your health?

Please type your name to sign that all information is valid and true.

Thank you for that information!

Mindful Objective does not diagnose, cure, or treat any illness or disease.
I underdstand.

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Thanks for becoming a Mindful Objective Health and Wellness client!

Health Intake Questionnaire

Your Journey to Wellness Starts Here!