Name

First Name

Last Name

Email Address

Telephone

Best Way to Contact You

Emergency Contact

Date of Birth

Age

Gender Pronoun

Place of Birth

Height

Weight

Passions/Interests

Education

Occupation

How Long?

How long have you been in your current occupation?

Relationship Status

List your top 3 Reasons for scheduling this consultation.

What other health-related issues do you have/have you had in the past?

Are you currently working with other health care practitioners?

How often do you eat dairy products?

How often do you drink soft drinks?

How often do you us margarine?

How often do you use butter?

How often do you drink coffee?

How often do you use tobacco?

How often do you use soy produts?

How often do you eat fish?

How often do you eat bakery goods?

How often do you eat nuts and seeds?

How often do you eat vegetables?

How often do you eat junk food?

How often do you eat fruits?

How often do you drink alcohol?

How often do you eat red meat?

How often do you eat fried foods?

How often do you drink water?

How often do you eat at restaurants?

How often do you cook / prepare food?

How many meals do you eat a day?

What foods do you crave?

Are you allergic or sensitive to any substances?

Have you had lengthy exposure to environmental toxins?

Yes

Do you currently follow or have you ever followed a restricted diet?

Please list all medications you are currently taking.

Please list all Supplements/vitamins/herbs currently used

Highest weight as an adult?

Age?

Lowest weight as an adult?

Age?

Are you satisfied with your energy levels?

Do you have regular bowel movements?

How many bowel movements do you have per day?

Per week?

Is it ever difficult to move your bowels?

Yes

Typical hours spent watching TV per day?

Typical hours on the computer per day?

Exercise –type/frequency/for how long?

Typical bedtime?

Typical hours asleep

Do you feel rested upon waking?

Are you satisfied with your primary relationship and/or your support system?

On a scale from 1 (low) to 10 (high), how stressful is your work?

On a scale from 1 (low) to 10 (high), how stressful is your current health status?

On a scale from 1 (low) to 10 (high), how stressful is your social/family situation?

Are you currently sexually active?

Select Forms of birth /STD control used currently or in the past:

Oral contraceptives

IUD

Condoms

Diaphragm

Tubal ligation/vasectomy

Withdrawal

Fertility Awareness

Patch

Other

Have you ever had an abnormal Pap smear?

If yes, please provide the date.

What steps were taken as a result?

Are you pregnant?

Are you actively trying to conceive?

If yes, how long have you been trying?

Are you currently breast feeding?

Are you currently on hormone replacement therapy (HRT)?

Have you ever been on HRT?

Do you currently do a monthly breast self-exam?

Date of last menstrual period:

Please list pregnancies:

Do you agree to notify me when you discover that you are pregnant during the course of our work together, please discontinue all herbal supplements and schedule an appointment so that we can discuss your herbal options *

Yes

Is it ever difficult to get your urine flowing?

Do you often have trouble achieving or maintaining an erection?

Please list major events in the last ten years of your life and the dates they occurred (include births, deaths, marriages, divorce, accidents, moves, jobs changes, miscarriages, illness and anything else you feel greatly impacted your life).

Holistic Nutrition + Herbal Medicine New Client - Intake Form

Holistic Nutrition + Herbal Medicine
New Client - Intake Form