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Intake Form
Client Information
Name
*
First
Last
Age
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Email
*
Reason for Visit (Prioritized)
*
2.
3.
Please describe any other symptoms or concerns:
Nutrition Information
How many ounces of water/day?
What kind?
What other beverages and how much?
Do you use artificial sweeteners?
Yes
No
Which sweeteners?
How often and in what?
Do you follow a certain diet or way of eating?
Do you eat breakfast?
Yes
No
What do you have for breakfast?
How much per week of these:
Fresh fruit
Raw vegetables
Fermented foods
Fast foods
Meat
Eggs
Dairy
Grains
Do you have any allergies?
What do you crave?
What foods do you dislike the most?
Why?
Timing
What is the first thing you do when you get up in the morning?
What time do you eat your first meal?
Last meal?
Which meal is your largest of the day?
Describe a typical “largest meal”
Movement
Do you exercise/move/participate in fun sweaty activity? If so, what and how often?
Do you look forward to it?
Yes
No
How do you feel when you are finished?
Emotional/Spiritual Health
Do you feel stressed most of the time?
Yes
No
Do you have anxiety attacks?
Yes
No
How do you relax and destress?
Do you experience depression?
Yes
No
Do you deal with repetitive, negative emotions?
Do you have a spiritual practice?
Yes
No
What is it?
Sleep
What time do you go to bed?
How long do you sleep?
Do you wake often?
Yes
No
Why do you wake and at what times?
Do you feel rested when you wake up for the day?
Yes
No
Do you have pain when you first get up?
Yes
No
Where do you have pain?
Does it go away upon moving?
How are your energy levels throughout the day?
Do you experience brain fog or trouble focusing?
Yes
No
Eliminations
Do you have daily bowel eliminations?
Yes
No
How many per day?
Please describe your elimination pattern.
Are you a Female?
Yes
No
Are you post-menopausal?
Yes
No
At what age did you enter menopause?
What were the characteristics of your menopausal experience?
Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?
Yes
No
Are you now, or in the near future, planning to become pregnant?
Yes
No
Is your menstrual cycle regular?
Yes
No
Longer than 28 days?
Yes
No
How long does your flow last?
Do you have cramps or clotting?
Yes
No
Would you describe the color of your menses as more red, more purple, or more brown?
Do you experience PMS, cyclical headaches, or cravings?
Supplements & Medications
Do you take any supplements?
Yes
No
What supplements, how often, and why?
Do you take any OTC medications routinely (such as Aleve or Aspirin)?
Yes
No
What OTC medications, how often, and why?
Do you take prescription medications (prescribed by a licensed medical professional?)
Yes
No
What prescription medications, how often, and why?
Medical History
Have you had any surgeries?
Yes
No
What surgeries and when?
Have you received any diagnoses from licensed medical professionals?
Yes
No
What diagnoses and when?
Naturopathic History
Have you ever been in consultation with a naturopath?
Yes
No
Why?
How long ago?
What was suggested?
Did you experience a good outcome?
What did you like about it?
What wasn’t as successful for you?
Do you have regular adjustments with a chiropractor?
Do you have regular body work/massages?
Please check all with which you are familiar
Homeopathy
Bach Flowers/flower remedies
Probiotics
Aromatherapy
Muscle response testing
Herbals
Sports nutrition
Enzymes
I understand that I am here to learn about natural health practices, that I will be offered information about whole food, supplements, herbs, homeopathy, flower essences, enzymes and more, as a guide to general good health. I acknowledge that this is a personal ministry offering spiritual counseling and personal empowerment. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I understand the information shared on this form and during assessments remains under strict confidentiality, but if needed will be used to consult other professionals while client’s identity remains anonymous. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on holistic wellness matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of cures for disease or medical conditions.
I have read the above terms and conditions of service by Sustain Wellness and understand and accept such terms:
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