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Individual Intake Form

Welcome to Mend Well Health’s Intake Form! We’re grateful you’ve chosen us to support yourself on the path to better health. Please fill out the following questions as thoroughly as possible, so we can gain a clear understanding of your unique needs and tailor our care to best serve you. Thank you for entrusting us with your well-being—we look forward to working together on your journey.

Individual Information

Birthday
Day
Month
Year
Gender
Male
Female
Other

Follow-Up Preferences

How would you prefer to be contacted:

Health History


Birth and Early Life:

Were there any complications during pregnancy or birth?
Yes
No

Trauma and Health Events:

Have you experienced any of the following (check all that apply):

Current Health and Lifestyle

Have you been diagnosed with any illnesses or disorders?
Yes
No
Are you currently experiencing:

Diet and Hydration

Sleep and Digestion

Do you wake feeling rested?
Yes
No
Are your bowel movements regular?
Yes
No

Mental and Emotional Well-being

Do you notice any recurring behavioural patterns?
Yes
No

Environment

Have you been exposed to any of the following:

Allergies and Sensitivities

Do you have any known allergies (food, medications, environmental)?
Yes
No
Are you sensitive to scents, sounds, or other sensory inputs?
Yes
No

Physical Activity

How physically active are you?
Sedentary
Light
Moderate
Active

Medications and Supplements

Are you currently taking any medications?
Yes
No
Do you take any supplements, herbs, or other remedies?
Yes
No

Pain and Mobility

Do you experience chronic pain?
Yes
No
Do you have any limitations in mobility or daily activities?
Yes
No

Stress Management

Family and Genetic History

Is there a family history of significant health conditions (e.g., heart disease, diabetes, mental health issues)?
Yes
No

Goals and Expectations

Consent for Data Collection

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Date
Day
Month
Year
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