Amble Wellbeing's Intake Form

first things first

Amble Wellbeing’s Intake Form

Please complete this intake form as thoroughly and accurately as possible. The information you provide helps me to better understand your needs and ensure that I offer the most appropriate support. All responses will be kept strictly confidential and used solely for the purpose of your care and service planning. Your honesty and attention to detail are greatly appreciated. Thank you!

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About You

Please provide your first and last name*

First Last

What are your pronouns?

What are the obstacles to your health?*

Existing Prescription Details

What prescription drugs are you taking (including birth control and hormones)? Please list how long you have been taking, the frequency you take them, and the dosage.*

Please list any non-prescription drugs, medications, herbs, supplements, or recreational substances you are currently using or have used in the past (including alcohol, tobacco, caffeine, and marijuana). For each item, include the following: how long you've been using it (or the time period you used it), how often you take it, the dosage, the reason for using it, and who recommended it (including if you chose it yourself).*

Do you have a history and/or diagnosis of:*

Please check all that apply.

Allergies to Food/Drugs/Mold

Heart Murmur or Palpitations

Anemia

Arthritis

Osteopenia or Osteoarthritis

Spinal Issues: Spinal fracture, Herniated/ruptured disk, Spinal fusion or discectomy, or Scoliosis

HIV Exposure

Asthma, Pneumonia, or Tuberculosis

IBS, Colitis, Crohn’s, Celiac, etc.

Autoimmune Disease

Implant or Prosthesis

Blood Pressure (High/Low)

Kidney or Bladder Disease or Infection

Cancer, Chemotherapy, and/or Radiation

Gallstones or Gallbladder Issues

Jaundice or Liver Issues

Chest Pain

Ringing in the ear(s)

Cholesterol/Triglycerides (High)

Parasites, Tropical, or Chronic Infection

Candida

Dry Eyes

Dry Mouth

Popping, Clicking, Locking of the Jaw

Dental Treatment Complications

Prolonged Bleeding When Cut

Diabetes

Dizziness, Fainting

Epilepsy, Convulsions, and/or Seizures

Shortness of Breath

Feet or Ankles, Swelling

Stroke or Cerebro-Vascular Accident

Glaucoma or Eye Surgery

Thyroid Disease or Medication

Amenorrhea or Menorrhagia

Headaches/Migraines

Ulcers or Intestinal Bleeding

Heart Attack, Disease, or Surgery

Fibromyalgia

Ehlers Danlos syndrome, Hypermobility Disorder

Anxiety or Depression

ADD, ADHD, Autism

PTSD or C-PTSD

None of the above

Please explain any of the above including date of diagnosis if applicable.*

Any other diseases or health concerns?*

Yes

Please list any other illnesses, diseases, injuries, history of addiction(s), substantial changes of weight, or anything else to help me clearly understand your health history and condition.*

Please list any medical procedures or surgeries with approximate date.*

Write n/a if this doesn't apply.

Do you experience any issues related to mucus or allergies? Please describe the consistency and amount of mucus you typically notice (e.g., thick, thin, clear, colored), and whether you experience post-nasal drip. Please also note if you often wake up with "sleep" or discharge in your eyes.*

Write n/a if this doesn't apply.

If applicable, please describe your menstrual and reproductive health history, including details about your cycle (length, bleeding duration, blood color), any spotting, clots, cramping, PMS symptoms, past period patterns, birth control history, and any issues like vaginal dryness or low libido.*

Write n/a if this doesn't apply.

Do you have any relevant family history of medical conditions?*

Yes

Please list any relevant family history of medical conditions*

e.g., heart disease, diabetes, cancer, mental health disorders

Please list any functional movements or everyday tasks that are difficult for you (e.g., reaching, bending, lifting, twisting, sitting, climbing stairs, standing, etc.). Also, note any areas in your body where you tend to hold chronic tension.*

e.g., heart disease, diabetes, cancer, mental health disorders

Movement & Meals

What is your daily activity level?*

Sedentary

Move Some

More a lot

Variable

What kind of movement/exercise do you engage in?*

To the best of your ability, please list everything you’ve eaten and drunk over the past three days, including approximate time frames for each meal, snack, or beverage.*

Is the above food journal typical?*

Yes

If not, what are some common meals that you have?

How often do you eat processed or refined foods, and what kinds do you usually have?*

How often do you cook meals at home versus eating out, ordering in, or picking up food? What types of meals do you usually choose when eating out?*

How do you feel about cooking? Do you enjoy it, find it stressful, avoid it, or feel neutral? Please share any thoughts or feelings you have about preparing food at home.*

What is your routine around eating? Are you often rushing or do you sit down and eat slowly? Are you multitasking when eating? Are you alone or with others? Please explain.*

Do you ever skip meals? If so, how often?*

Please describe what and how much you typically drink in a day, including water, teas, coffee, alcohol, and other beverages. Include approximately how much you drink of each, the typical temperature (hot, cold, room temperature), and whether you usually add ice.

Please check any of the below that you often experience*

Check all that apply.

Bloating after eating

Heaviness after eating

Rarely hunger or irregular hunger

Hanger (getting angry/irritable when hungry)

Frequent burping

Frequent flatulence

Acid Reflux, or indigestion

Constipation

Diarrhea

Other

None of the Above

If you selected any digestive issues above, please share more details about each—such as when it started, how often it occurs, what makes it better or worse, and anything else you think is relevant.

How frequently do you urinate? What color is your urine? Do you notice a smell, cloudiness, or bubbles?*

How frequently do you sweat? Do you find it easy or challenging to sweat? Do you notice a smell?*

Describe your skin type and any skin-related concerns: Is your skin typically oily, dry, or a combination? Has this changed over time? Do you experience flushing, rashes, or skin allergies?*

What is your typical energy level?*

Provide details about your energy level: When do you notice it shift? What affects it?*

What is your quality of sleep?*

Please check all that apply.

Restful

Restless

Not enough

Too much

Frequently interrupted/Difficulty staying asleep

Difficulty falling asleep

Variable

Provide details about your sleep: When did this start? What makes it better? What makes*

Describe a typical day in your life: What does a usual day look like for you—from morning to evening? If your workdays and days off are noticeably different, feel free to describe both. Include details such as your activity level, meal times, rest periods, stress levels, and any routines or habits you tend to follow.*

What does your morning typically look like? What time do you usually wake up, and what’s the first thing you do after getting up? Please describe your usual morning routine, including any habits, activities, or rituals you follow before starting your day.*

What does your evening and bedtime routine look like? What time do you usually go to bed, and what are you typically doing in the hour or so before? Please include any regular activities, habits, or rituals that are part of winding down for the night*

What is your level of stress?*

What are the sources of your stress?*

What do you do to counteract stress?*

How often do you experience anxiety?*

How does anxiety present for you?*

How often do you feel depressed?*

How does depression present for you?*

Would you say you have more of a tendency toward anxiety or depression?*

How often do you have difficulty concentrating?*

How often do you have difficulty remembering things?*

Is there anything else you’d like me to know about your attention, focus, or memory? This could include things like trouble concentrating, forgetfulness, difficulty staying organized, challenges with learning or processing information, or anything else you’ve noticed. Feel free to share any patterns, situations where it gets better or worse, or strategies you currently use to manage it.*

What does self-care look like for you currently? Do you have any tools or practices that you do regularly?*

Have you practiced any form of yoga before, including breathwork or meditation? If yes, please provide details such as the style(s), frequency, and your overall experience.*

What does your support system look like? Who do you turn to for emotional, practical, or social support (e.g., friends, family, community, coworkers, professionals)? Please include how connected or supported you feel, and anything you'd like to share about your current relationships or sense of community.*

What do you do for fun? What are your hobbies?*

What brings you joy? What are your sources of hope?*

Do you have any spiritual or religious practices that are meaningful to you? If so, please feel free to describe them, including how they show up in your daily life (if at all), and any ways they support your well-being or personal values.*

Is there anything else you would like me to know before our first meeting?*

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Preferred Method of Contact

Email Address*

Email Address Confirm Email Address

Primary Phone*

first things first