Patient Intake Form
All Information Is Secured And Confidential!
First Name*
Required field!
Middle initial
Required field!
Last name*
Required field!
Date Of Birth*
Required field!
Location of Birth (City & State) **ONLY Required For Natal Chart Readings**
Required field!
Birth Time **ONLY Required For Natal Chart Reading)
Required field!
Email*
Required field!
Phone Number*
Required field!
Address*
Required field!
City*
Required field!
State*
Required field!
Zip / Postal Code*
Required field!
Country*
Required field!
Ethnicity (Check all that Apply)*
Required field!
Gender*
Required field!
Height*
Required field!
Weight*
Required field!
Do You Smoke?*
Required field!
Do You Drink?*
Required field!
Blood Type*
Required field!
Blood Type RH Factor*
Required field!
Current Medications/Supplements
List any medications or supplements you take
Required field!
Foods You Eat (Check all That Apply)*
Required field!
What Cooking Oils Do You Use?*
Required field!
What Kind Of Salt Do You Use?*
Required field!
How Much Water Do You Drink Daily?*
Required field!
How Many Meals a Day Do You Eat*
Required field!
Current Health Issues & Allergies*
Required field!
Operations/Surgeries
Required field!
How Much Sleep Do You Get On Average?*
Required field!
How Much Physical Activity Do You Get On a Weekly Basis?*
Required field!
Describe Your Stress Levels and How You Manage Stress*
Required field!
How Would You Describe Your Outlook And Level Of Satisfaction In Your Life
Required field!
Have You Received Any Vaccinations?*
Required field!
How did you find out about EV Health?
Required field!
Additional Notes
Required field!