Client Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Sex * Male Female Age * Laterality * Right Handed Left Handed Hormonal Status * Normal Hormonal Status Pre-Menopausal Post-Menopausal Pregnant Breast-Fedding On Birth Control On Hormones Familiarity with GNM/GHK * Very Familiar Somewhat Familiar New to this Work Medications: Please list any medications you are currently taking. Symptoms: * Please give a brief description of the symptoms and diagnoses you would like to cover in the session. Timeline: * Please give, to the best of your ability, a timeline of when your symptoms started/date of diagnoses. Organs: * Please list the organs and areas of the body that have been affected. Life Events * Please list the major life events impacting you. Issues/Concerns Please list any other issues/concerns Thank you!