Intake Form - Christine Doctor

Please fill out the Intake Form and fill it out prior to purchasing a service. Once we have this information we are better prepared to provide you with the answers and support you need. You can fill it out online or download the PDF to fill in and send it by email to shop@christine.doctor

Click here – Intake Form (PDF)

FILL OUT THE INTAKE FORM ONLINE

Family Name: *

First Name: *

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Birth Date/Time:

Profession

Social situation

Single
Partnership
Family

Profession satisfaction

Satisfied
Unsatisfied

Sports Activities

None
Sometimes
Regularly

Body weaknesses and injuries

Diseases / Symptoms / Main Concern

File Upload - Please add any clinical reports, blood- and tests reports, x-ray pictures, or similar

Click or drag a file to this area to upload.

Do you take minerals?

Never
Sometimes
Regularly

Do you take vitamins?

Never
Sometimes
Regularly

Do you take other prescription drugs or remedies?

Never
Sometimes
Regularly

Do you take dietary supplements?

Never
Sometimes
Regularly

Do you have allergies or intolerances?

Inside Home Allergens?

Outside Home Allergens?

Environmental Influences (Geopathic Stress):

Do you have children?

Pregnancies?

Surgeries in your life

Difficult diseases in your life

Most frequent health issues in your life

All therapies during last 12 months & results you got

Please list all your symptoms, pain, impairments, major and minor ailments

How do you sense these symptoms, pain: pressure, pulsating, choking, pounding, cutting, etc. Please provide a good description if possible, with visualization and imaging as best as you can.

Where do you feel these symptoms/pain; are these radiating and, if yes where?

If worsening occurs which are the factors aggravating the symptoms/pain?

Examples: Movement, lie down, pressure, a temperature higher or lower than usual, storms, weather changes, water contact, specific time of the day, during sleep, seasonal, light or excessive sunshine, when eating, when excreting, when menstruating, nervous, stress, dispute, grief, anxiety, worries, full moon.

Same question regarding when you feel better and your symptoms are softening.

Please list out details

Do you think your health issues may be caused by your psycho-mental state of mind?

Do you have also some other “minor ailments”, temporary or softly disturbing you?

Which are the diseases you had in the past, which manifested in an acute way, and which healing easily?

Did you have in your childhood recurrent health conditions?

How many and if possible, which vaccines did you get.

Was there any reaction thereafter, any special symptoms?

Which other diseases, surgeries, special conditions, and therapies did you have and when?

Have you noticed any skin changes, eczemas, which kind, and when?

Were these treated, which therapies were applied?

Do you feel cold or heat more than average?

Do you take your shower warm or cold?

Are you a thirsty person

Do you prefer to drink warm or cold liquids?

Warm
Cold

Which are your preferred drinks and food?

Do you sometimes want some specific food or drink but you are having incompatibility or adverse reactions (such as allergies, nausea, vomiting, diarrhea, etc.) when consuming them?

Do you prefer saltier foods?

Do you try to avoid salt?

Do you prefer sugar (sweet) foods?

Do you prefer fattier foods?

Do you try to avoid fats?

Do you sweat much?

Do you see or feel any special reactions or symptoms when excreting stool, urine, period bleeding, sweating?Which body zones do you experience sweat? Please list: (copy)

Do you have anxiety, fears, panic when thunderstorms are occurring, claustrophobia, height fear, small rooms, public speaking, or performing?

Do you dream often, and do you see repeatedly dreams; which are your dreams, do you remember these?

Which are now your major health concerns and targets?

Date / Time

Date

Time