06 25433375

Intake & Anamnesis

Intake and anamnesis form

Complementary therapies & lifestyle advice

Important information

This intake and anamnesis form is completed digitally prior to the first consultation. During the first consultation the form is reviewed together with the client, supplemented or corrected if necessary, then printed out and signed by both the client and the therapist.

By signing, the client confirms that the information provided has been filled in truthfully and that any additions or changes were discussed during the intake conversation.

Vuurdraak's services are complementary in nature and do not replace regular medical, psychological or paramedical care.

Personal details
Reason for your visit
Current health

Do you currently have one or more of the conditions listed below?

Medical care
Are you currently under the care of a doctor, specialist, psychologist, psychiatrist, physiotherapist or other healthcare provider?
If it is considered to be in the interest of your health, Vuurdraak may advise you to contact your treating healthcare provider.
Medication, supplements & allergies
Are you currently taking any medication?
Are you currently taking any nutritional supplements?
Do you have any allergies or hypersensitivities?
Are you currently pregnant or is there a possibility that you are pregnant?
Lifestyle and habits
Do you smoke?
Do you regularly consume caffeinated drinks such as coffee, tea, energy drinks or cola?
Do you ever drink alcohol?
Do you ever use drugs?
Energy level
Sleep quality
Do you exercise regularly?
How would you rate your current eating pattern?
Workload and stress
How do you currently experience your stress level?
Additional information & expectations
Consent and Informed Consent

By ticking the declarations below, I confirm that: (all required)

Declaration and signature

The undersigned declares that the information provided has been filled in truthfully and that any additions or changes were discussed during the intake conversation.

The digitally completed intake form is printed out, discussed and signed by the client and the therapist during the first consultation. The signed version is added to the client file.

Therapist name: David Chung
The signatures of the client and the therapist are placed on the printed version during the first consultation.

Privacy statement

Your personal data is treated confidentially and processed in accordance with the General Data Protection Regulation (GDPR). Your data is used solely for client administration, record-keeping, communication, invoicing and complying with legal obligations. Data is not disclosed to third parties without your consent, unless Vuurdraak is legally obliged to do so. Client files are retained in accordance with the statutory retention periods.

Vuurdraak — Complementary therapies & lifestyle advice · Uithoorn, the Netherlands

WhatsApp