Intake Form

Your right to privacy is our concern. All information is held in the strictest confidence. Confidential, all Applicable rights reserved.

Adult Health History

Name

First

Last

Date of Birth (DD-MM-YYYY)

Age

Occupation

Employer

Works hours/week

Marital Status

# of kids

Highest level of Education

Insurance Company

Policy

Group #

Name of Insured

First

Last

Relationship to Insured

Emergency Contact

First

Last

Phone

Relationship to Emergency Contact

Name of your Regular Physician and associated phone number

How did you hear about us?

Current Health

What are your main health concerns/reasons for your visit? Please list them in order of importance

Please list any Additional Questions or Expectations of the appointment today

The general state of your health is

Are you currently seeing (a) medical specialist (s)? If yes, for what reason?

When was the last time you had blood work or other lab testing performed (month/year) and what was it for?

Is this your first time working with a Holistic Nutritionist for any of your main health concerns?

Yes

No

Did any of your family have the following?

Father

Mother

Siblings

Grandparents

Anything else not listed?

Considerations – Scar Tissue

List All Surgeries and Reasons for Hospitalizations (Include any cosmetic procedures) with their dates::

List All Accidents, Injuries, or Physical Traumas:

Have you had any X-Rays? If yes, when and why?

Have you had any MRI/Cat scans? If yes, when and why?

Have you had any ultrasounds? If yes, when and why?

Considerations – Acidic pH

Please mark if any of the following feels applicable to you:

Please List All Sensitivities/Allergies/Reactions (includes drugs, food, and environmental):

If applicable, please list all travel outside the US over the last 5 years:

Have you consumed any untreated river water while hiking or camping?

Yes

No

Have you ever done a Colon or Liver Cleanse? If yes, when was your last one?

Have you ever done a fasted? If yes, when was your last one?

How many rounds of antibiotics had within the last year?

How many rounds of antibiotics had within the past 5 years?

How many rounds of antibiotics had within your lifetime?

Current use

Past Use

If yes to any of the above, please list frequency (packs/cups/ounces per day and how many days a week):

Had the Disease

Received Immunization for

Any vaccine reactions?

Medication: Please list your dosage and length of time you have been taking any medication, herbs, or supplements:

Did you grow up near any refinery, polluted area, or in-home with leaded paint? If so, what sort of pollution were you exposed to?

Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials?

Have you ever experienced shortness of breath, memory fog, fainting, or any peculiar symptoms after installing new carpet, paint, furnishings, or any other home refurbishing?

Are you particularly sensitive to perfumes, gasoline, or other vapors?

Do you use pesticides, herbicides, or other chemicals around your home?

How many amalgam ‘silver’ fillings do you have?

Does your perspiration have an odor?

Considerations – Emotional Charge

Please check any you feel are applicable to you:

Have you ever been witness to or subjected to acts of physical violence, abuse, or emotional trauma? If so, what age(s)?

Have you ever been in a severe accident or injured in a life-threatening situation? If so, what age(s)?

Stress History: Please list the five most significant, stressful events/relationships/situations in your life, with the approximate dates they happened:

How Many hours do you sleep each night?

How many minutes does it take for you to fall asleep at night?

Do you sleep through the night uninterrupted?

Yes

No

If you wake up, whats the time and reason?

Do you dream?

Yes

Not Often

No

Does any of the following apply to you:

Frequent Nightmares

Grinding Teeth

Not feeling refreshed after waking up

Snoring

Present weight (lbs)

Height

Weight 1 year ago (lbs)

Ideal weight (lbs)

Maximum weight and when?

On average, describe your energy level from 1-10 waking? (10= high, 1= very low energy)

The average number of bowel movements per day?

The number of days each week without a BM?

Do you regularly feel energetic?

Yes

No

Do you regularly feel fatigued?

Yes, and it prevents me from doing what I need to do

Yes, but it does not prevent me from doing what I need to do

No

If yes, when is it the worst?

Morning

Afternoon

Evening

After Eating

Considerations – Biomechanical Misalignment

Do any of the following apply?

How often do you practice yoga or other therapeutic stretching (days per week)?

How many times a month do you get a massage?

How often do you do cardiovascular exercise? (days per week and how long each session is)

Sexually Active?

Yes

No

Healthy Libido?

Yes

No

Sexually satisfied?

Yes

No

What Hobbies/Interests bring you the most Happiness?

Are you working with a professional counselor, psychologist, social worker, pastor, or another therapist?

Yes

No

Are you happy with your spiritual practice?

Yes

No

Are you active in your spiritual practice?

Yes

No

Do you enjoy your job?

Yes

No

If applicable, Female Reproductive -If not, skip to end

Do You Know How to Identify Genital Warts on your partner?

Yes

No

If menopausal, at what age did it occur?

Please list times pregnant, how many births/miscarriages/abortions. Any difficulty getting pregnant?

At what age did your periods begin? How long do they last and how many days are between cycles?

Are your periods…

Regular (4-6 days)

Long

Short

None

Is your menstrual flow…

Regular

Heavy

Scant

What color is the blood?

Light

Medium

Dark

Do you spot or bleed between periods?

Yes

No

Do you have…

Do you have any of the following PMS symptoms

When was your last pap smear?

I understand that the extent to which my health goals are successful will be determined by the amount of energy, commitment, and dedication I give to support the work I am endeavoring into

I accept responsibility for my health

Interested in Our Services?

Adult Health History

Current Health

Considerations – Scar Tissue

Considerations – Acidic pH

Considerations – Emotional Charge

Considerations – Biomechanical Misalignment

If applicable, Female Reproductive -If not, skip to end

I understand that the extent to which my health goals are successful will be determined by the amount of energy, commitment, and dedication I give to support the work I am endeavoring into