Health Consultation Intake Form Template

A whole-systems intake for functional, integrative, and nutrition practice: sleep, digestion, stress, movement — and the health story in the client's own words.

A Different Map of Health

Functional medicine, nutrition therapy, health coaching, and integrative practice start from a different question than conventional intake: not what hurts but how is the whole system running. Sleep feeds hormones; stress reshapes digestion; movement alters energy. An intake that only asks about symptoms misses the system entirely — so this brief asks about the system.

The Systems Review

Six domains, each a couple of quick items — rating scales for how things run, short fields for specifics:

  • Sleep. Hours, quality, timing, and whether mornings feel like recovery or continuation.
  • Digestion. The system functional practitioners interrogate first — patterns, triggers, comfort.
  • Energy. Not ‘are you tired’ but the shape of the day: where energy rises, where it collapses.
  • Stress and recovery. What the load is, and what — if anything — genuinely offsets it.
  • Movement. What the body does in a typical week, honestly counted.
  • Nourishment. A typical day’s eating, described rather than judged.

The Story and the Substances

Two sections give this brief its depth. First, the narrative: a generous long text field inviting the full health story in the client’s own words — when it started, what they’ve tried, what they believe is going on. Practitioners in this tradition read the story the way conventional medicine reads a lab panel: it is the primary data.

Second, the full substance list — supplements included, prominently. In wellness practice the supplement shelf is half the pharmacology, and clients routinely omit it. The brief asks for everything currently taken: prescribed, over-the-counter, herbal, and the powders. Prior labs and specialist letters ride along through document upload.

The Destination

One closing question anchors the work: what would ‘better’ actually look like for you? Concrete client language — sleep through the night, climb stairs without pausing — becomes the plan’s success measures, and at review time the brief can recall those words and ask against them.

Allow twenty unhurried minutes; this brief is meant to be completed reflectively, not in a waiting room. The surrounding practice toolkit sits in the consultation collection and the healthcare forms shelf.

Frequently Asked Questions

Which practices is this built for?

Functional and integrative medicine, nutrition therapy, dietitians, health coaching, naturopathy, and lifestyle programs — anywhere the plan of care works through systems and habits rather than a single presenting complaint.

Why so many lifestyle questions?

Because they are the intervention. In systems-based practice, sleep, stress, movement, and nourishment are the treatment surface — the intake has to map them or the plan guesses.

Should clients really list all their supplements?

All of them — interactions and redundancies hide in exactly the products clients assume aren’t worth mentioning. The brief says so explicitly, which is most of the battle.

Can this work alongside conventional medical care?

It’s designed to. The records section collects results from the client’s conventional providers, and the story section helps any practitioner see what the client has already been through and told.

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