Download Chronic Fatigue Intake Form

Chronic Fatigue Intake Form
The first part of this form is for the client to fill out either alone or with the practitioner.
The second part of this form is for the practitioner’s use. Use this form at the beginning
of your relationship and complete it again after one or more sessions.
Client Name: __________________________________ Date: _________________
Pain Rating: On a scale of 1 to 10, 10 being the worst:
____How severe is your fatigue on average?
____How problematic is this issue for you as a whole?
____How much does it interfere with your day to day activities?
____How much does it interfere with your relationships?
____How many times out of 10 do you cancel social plans because of your fatigue?
____How at risk is your work or schoolwork because of these issues?
Details: Do you occasionally or often experience the following:
︎Troubled relationships ︎Issues with spirituality / the divine ︎Feelings of unsupported
︎Negative self-talk ︎Feeling helpless/powerless ︎Difficulty creating things ︎Feelings
of shame ︎Feelings of worthlessness ︎Feelings of hopelessness ︎Irregular sleep
patterns ︎Difficulty concentrating/Brain fog ︎Physical aches and pains ︎Joints
popping (indicates adrenal) ︎Overeating ︎Digestive problems or discomfort ︎Loss
of appetite ︎Loss of interest in activities ︎ Fear of the future ︎Wanting to run away
︎Wanting to quit ︎Feeling taken for granted
︎Other (please describe) _________________________________________________
______________________________________________________________________
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Current:
How many hours per day do you sleep on average?____________________________
Is the fatigue constant or is it up and down / irregular?___________________________
What (if anything) seems to make it worse, or trigger an episode? _____________________
____________________________________________________________________________________
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What are you currently doing to help this problem? _____________________________
______________________________________________________________________
What makes this problem better? ___________________________________________
______________________________________________________________________
Please list any other medications, supplements or therapies you are using: __________
______________________________________________________________________
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History:
When did this start for you? _______________________________________________
What (if anything) triggered the onset of this problem? __________________________
______________________________________________________________________
Please describe any traumas you feel may be related to this problem, even
indirectly: ______________________________________________________________
______________________________________________________________________
______________________________________________________________________
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What have you done to treat it in the past?____________________________________
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Please list any family members who have / have had similar problems: _____________
______________________________________________________________________
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Have you been exposed to any known environmental toxins? ︎Yes ︎No
Goals:
If you didn’t have this issue, what would you be able to do?_______________________
______________________________________________________________________
If you didn’t have this issue, what would want to do?____________________________
______________________________________________________________________
If this issue went away tomorrow, how would you feel? __________________________
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For staff use only
Metaphysical connections / Emotional issues: (check off for problematic answers)
︎Are you okay with being connected to others?
︎Is something preventing you from being connected to others?
︎Are you okay with supporting yourself?
︎Are you okay with going with the flow of life?
︎Are you okay with managing all of life including its challenges?
︎Is part of you wanting to “quit” life?
︎Is part of you wanting to give up / stop living?
︎Does part of you / all of you feel you’ll never be good enough?
︎Is the fatigue driven by part of you needing to / wanting to run away?
︎Is the fatigue protecting you from something?
︎Are you worthy of being happy?
︎Are you worthy of love?
︎Are you worthy of being fulfilled?
List other questions/issues that come to mind intuitively:
______________________________________________________________________
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Body Balance: Check balance of the following body parts / systems that are often
implicated in Chronic Fatigue:
Systems
Circulatory System ___%
Digestive System ___%
Endocrine System ___%
Immune System ___%
Lymphatic System ___%
Nervous System ___%
Glands
Left Adrenal ___%
Right Adrenal ___%
Pineal Gland ___%
Pituitary Gland ___%
Thyroid ___%
Parathyroid ___%
Organs
Sm. Intestine ___%
Colon ___%
Left Lung ___%
Right Lung ___%
Left Kidney ___%
Right Kidney ___%
Chakras
Heart ____%
Solar Plexus ____%
Body Connection: Check connection level of the following:
Spirit body to Physical body connection ____%
How much of the spirit is in the body: ____%
Things to monitor later down the road:
︎____________________________________________________________________
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