Intake Form Intake Form Client InformationFirst Name*Last Name*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* How Did You Hear About Us?StatisticsAgeBirthdate GenderHeightWeightTarget WeightWeight one year agoBlood TypeFamily/Living ArrangementNumber of Children & AgesOccupationExercise/RecreationHistory1. Have you lived or traveled outside of the United States? If so, when and where?:2. Have you or your family recently experienced any major life changes? If so, please comment:3. Have you experienced any major losses in life? If so, please comment:4. How much time have you had to take off from work or school in the last year?0 to 2 days3 to 14 daysmore than 15 daysHealth Concerns5. What are your main health concerns? (Describe in detail, including the severity of the symptoms):6. When did you first experience these concerns?7. How have you dealt with these concerns in the past? doctors self-care other (please describe in question 8) 8. Have you experienced any success with these approaches?9. What other health practitioners are you currently seeing? List name, specialty and phone # below. 10. Please list the date and description of any surgical procedures you have had. 11. How often did you take antibiotics in infancy/childhood, as a teen, and as an adult? Please describe all three12. List any medicine you are currently taking: 13. List all vitamins, minerals, herbs and nutritional supplements you are now taking: 14. Have any other family members had similar problems (describe)?15. Are there any foods that you avoid because of the way they make you feel: If yes, please name the food and the symptom.16. Do you have symptoms immediately after eating like bloating, gas, sneezing or hives: If so, please explain:17. Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain:18. Are there foods that you crave: If so, please explain:19. Describe your diet at the onset of your health concerns:20. Do you have any known food allergies or sensitivities?21. Which of the following foods do you consume regularly? soda diet soda refined sugar alcohol fast food gluten (wheat, rye, barley) dairy (milk, cheese, yogurt) coffee 22. Are you currently on a special diet? ovo-lacto diabetic dairy restricted or dairy-free vegetarian vega paleo blood type refined sugar-free gluten-free other (please describe in question 26) 23. What percentage of your meals are home-cooked?10203040506070809010024: Is there anything else we should know about your current diet, history or relationship to food?Intestinal Status25. Bowel Movement Frequency1-3 times per daymore than 3 times per daynot regularly every day26. Bowel Movement Consistency soft & well formed often float difficult to pass diarrhea thin, long or narrow small and hard loose but not watery alternating between hard and loose 27. Bowel Movement Color medium brown very dark or black greenish blood is visible yellow, light brown chalky colored greasy, shiny alternating between hard and loose 28. Do you experience intestinal gas: If so, please explain if it is excessive, occasional, odorous, etc.29. Please check any of the following conditions that apply to your history Cancer Heart Disease Hepatitis Venereal Disease Diabetes High Blood Pressure High Cholesterol Kidney Disease Thyroid Disease Depression Asthma Allergies Anemia Chronic Yeast Infections Other Briefly describe your symptoms, chosen treatment(s), and dates.Health Hazards30. Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?31. Do odors affect you?32. Are you or have you been exposed to second-hand smoke?33. Do you have mercury amalgam fillings?Lifestyle History34. Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time.35. Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?36. How do you handle stress?37. Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?Are you female?YesNoFor Women OnlyHow are/were your menses? Do/did you have PMS? Painful periods: If so, explain.In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?Have you experienced any yeast infections or urinary tract infections? Are they regular?Have you/do you still take birth control pills: If so, please list length of time and type.Have you had any problems with conception or pregnancy?Are you taking any hormone replacement therapy or hormonal supportive herbs: If so, please list here if not listed above: Mental Health Status38. How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger?39. On a scale of 1-10, one being the worst and 10 being the best, what is your ususal level of energy.1234567891040. At what point in your life did you feel best? Why?Other41. Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.42. Who in you family or on your health care team will be most supportive of you making dietary change?43. Please describe any other information you think would be useful in helping to address your health concern(s):44. What are your health goals and aspirations?45. Though it may seem odd, please consider why you might want to achieve that for yourself:
