Healthy Family Formula Client Intake Form
Personal Information
If you are filling this form out for a child or other family member, please just answer to the best of your ability with answers that pertain to your child or family member. Parents, do consider filling out an intake form for yourself (optional). The more information about the whole family, the better.
Full Name
*
First Name
Last Name
Date
*
Birthdate
*
Gender
Female
Male
Transgender
Other
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (cell preferred)
*
-
Area Code
Phone Number
Marital Status
*
Single
Married or in a Long-Term Partnership
In a Relationship
Divorced
Widowed
Remarried
I Am a Child
Number of Children
*
1
2
3
4
More
0
Please summarize all symptoms that are challenging you right now. List the top 10 and then take some time to explain.
*
Name of Requested HFF Practitioner. If you do not have one in mind, leave this blank, and we will assign an HFF-Trained Practitioner to be your Coach.
*
HFF Practitioner Name. Visit our website to view our practitioner profiles.
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Diet and Food
5 Day Food Diary
Please fill in the following Food Diary for the last 5 days. Please be as honest as you can as this will give your coach a good idea of your usual diet. Be sure to include liquid intake. Report in the rows as follows: 1. Breakfast; 2. Snack; 3. Lunch; 4. Snack; 5. Supper; 6. Snack; 7. Other/Extra. Reasons for eating may include hungry, hangry, raise energy levels, tasted good, filled a craving, was upset, etc. How you felt afterward may include physical, mental, emotional responses; also pay attention to responses or symptoms that occur up to a few days after you or your child or family member ate the food.
Day 1
Day 2
Day 3
Day 4
Day 5
What kind of water do you drink? Bottled, tap, filtered, well, etc. (If filtered, what kind of filter do you have?)
*
Do you use a microwave?
*
Yes
No
Sometimes
In the Past
How many times do you eat out per week?
*
1
2
3
4
5
6
7
9
10 or more
0
Do you cook?
*
Yes
No
I want to but don't have time
Sometimes
In the past but not now
Do you eat non-organic food?
*
Yes
No
Sometimes
Do you eat conventional non-organic meat?
*
Yes
No
Sometimes
Do you adhere to any sort of special diet such as vegetarianism, paleo, low-carb, GAPS, etc.? Or have you in the past?
Do you have any food restrictions?
*
Yes
No
If yes, please explain.
Have you been tested for these food sensitivities/allergies?
*
Yes
No
If yes, what were the results?
Have you ever done an elimination diet?
*
Yes
No
If yes, what did you discover?
Have you ever “dieted” before?
*
Yes
No
If yes, please explain.
Would you consider yourself an emotional eater?
*
Yes
No
If yes, please explain.
What were your family eating habits when you were growing up?
*
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Current Lifestyle and Environment
Please describe your typical day. If you are filling this out for a family member, please describe their typical day.
*
What do you do for exercise? List how many times a week you exercise (running, aerobics, walking, wall climbing, playing sports, going to the gym, etc.).
*
How much do you move in a day? (Note: movement entails puttering around, walking to the store, playing with kids, fixing up things around the house, etc. Anything that gets you off the couch and on your feet.)
*
Even more importantly, which of the above do you enjoy doing, and which do you do because you feel you should?
*
What do you do to rest and relax?
*
Do you over-exercise or are you an athlete who trains at an intense level?
*
Yes
No
If so, please explain.
Do you smoke?
*
Yes
No
In the past
If so, for how many years?
Do you drink alcohol?
*
Yes
No
In the past
If yes, how many drinks do you have per day, per week, or per month. If in the past, please elaborate.
Do you do any recreational drugs?
*
Yes
No
In the past
If yes, how often do you partake in that drug per day, per week, or per month. If in the past, please elaborate.
Do you have any pets?
*
Yes
No
In the Past
If so, are your pets indoors?
Yes
No
Sleep
How many hours of sleep do you get on average per night?
*
Less than 6
6
7
8
9
10 or more
What time do you go to bed at night?
*
Do you have any trouble sleeping or staying asleep?
*
Yes
No
Sometimes
If yes or sometimes, please explain.
Do you feel rested when you wake up?
*
Yes
No
Sometimes
If no or sometimes, please explain.
Do you work shift work?
*
Yes
No
Sometimes
If yes or sometimes, please explain and tell me how long you have been working shift work.
Environmental Exposures/Toxins
Do you have amalgam fillings?
*
Yes
No
I had them removed
If you had them removed, was it with a dentist trained in safe removal? When did you have them removed, and why?
If you have had any other dentistry work (such as root canals, braces, or if you wear a dental splint on teeth), please describe below.
Do you receive regular fluoride treatments?
*
Yes
No
In the past
What kind of toothpaste do you use?
*
What kind of deodorant do you use?
*
Please indicate what chemicals you are exposed to on a regular basis (check all that apply)
conventional cleaners
new furniture
exposure to building materials such as glues, paint, sealers, etc.
pesticides
printer ink (office)
air pollution exposure
chemical exposures
geo-physical stressors
heavy metal accumulation in hair
mold exposure at work or home
noise pollution
radon
light pollution
radiation (airplanes, computers, x-rays)
smoking or second hand smoke exposure
toxic exposures in air (smog)
water pollution
electromagnetic fields (computers, wifi, etc.)
Other
Do you have an air filter in your home?
*
Yes
No
If yes, what brand?
Do you have an air filter at your place of work?
*
Yes
No
If yes, what brand?
Have you ever done any sort of detoxification?
*
Yes
No
If yes, what program, and what were the results?
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Hobbies and Leisure Time
What are your hobbies? What do you do for fun?
*
What do you do for work? This can be paid or unpaid because it is all work! Please tell me if you work outside the home or work from home. Stay at home parents, volunteers, what you do is definitely work, so list it here if this is the work you do.
*
Travel: Have you travelled abroad?
*
Yes
No
If so, when and where?
Have you ever been ill while travelling or shortly after returning from travel abroad?
Yes
No
If so, please explain.
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Mental, Emotional, Spiritual Health
Do you experience stress in your life?
*
Yes
No
Sometimes
If yes or sometimes, please explain and list your stressors.
Have you experienced any trauma in your life?
*
Yes
No
If so, when? You can explain if you like or leave this question blank.
Do you have the support of family and/or friends in your life and in this journey you are about to take toward regaining your health?
*
Yes
No
Some support
Please explain and list your supports.
Do you have any people in your life that are a barrier to you regaining your health?
*
Yes
No
Some
If yes or some, please explain.
Do you have any spiritual beliefs?This could be religious beliefs or even seeing the spiritual benefits of nature or believing in something greater than ones’ self. You may not believe in any of that, and that is entirely fine to say that here, as well. You can also skip this question.
Yes
No
I would prefer not to say
If you have spiritual beliefs, please explain if you like.
Are you happy?
*
Yes
No
Sometimes
Please explain.
Do you have financial worry?
*
Yes
No
Somewhat
Do you have any current stressful relationship issues?
*
Yes
No
Do you suffer from or have you ever suffered from the following (please check all that apply):
Addictions (can be anything from gambling to sugar to alcohol to drugs to sex, etc.)
Anger
Anxiety
Bipolar
Depression
Despair
Exhaustion
Fear
Guilt
Grief
Impatience
Irritability
Lack of motivation
OCD
Overwhelm
Panic attacks
Perfectionist
PTSD
Sadness
Schizophrenia
Type A Personality
Workaholic
Worry
Worthlessness
Just a bad mood or feeling up and down and not quite right or happy
Other
If you have an addiction, please specify it here and comment if you like.
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Physical Health (Symptoms Checklist)
Explain your current state of health in your own words.
Do you have any digestive or gastro-intestinal problems?
Yes
No
In the past
If so, please explain.
I am going to ask you about your poop. Yes, your poop. This is very important, so please do humour me. Have a look at the Bristol Stool Chart below and indicate which number best describes your current bowel movements. You can choose more than one, but please do try to stick to the 2 most common for you.
1
2
3
4
5
6
7
Please check all of the symptoms you are currently experiencing.
Absentmindedness
Appetite poor
Appetite excessive
Bad breath
Bedwetting
Bleeding gums
Bone spurs
Bradycardia
Bruise easily
Bruxism (grinding teeth)
Burning (stomach)
Canker sores
Carbohydrate sensitivity
Cataracts
Cavities
Catch colds easily
Chronic indigestion
Chronic infections
Chronic inflammation
Chronic pain
Chronic sinus infections
Coating on tongue – white
Coating on tongue – yellow
Coating on tongue – brown
Cold often
Concentration difficult
Constipation
Constipation and diarrhea (alternating)
Crave salt
Crave carbs/sugars
Cramps (menstrual)
Cramps (muscle)
Cramps (stomach)
Decreased ability to handle stress or pressure
Decreased tolerance of others
Diarrhea
Difficulty building muscle
Dizziness
Dry skin
Edema, fluid retention
Excessive facial or body hair
Excessive hunger
Fatigue
Fatigue not relieved by sleep
Feel best in the evenings
Feel faint often
Feel unwell often
Feel weak
Fibrocystic breasts
Flatulence
Foggy thinking
Forgetful
Get confused often
Hair brittle
Hair loss
Hard to act or think quickly
Hay fever
Headaches
Heartburn, reflux, or GERD
Heart Palpitations
Hemorrhoids
Hot flashes
Impotence
Indigestion
Intestinal gas
Losing muscle mass
Low blood pressure
Low body temperature (below 98 degrees orally)
Low blood sugar (hypoglycaemia)
Low energy
Low libido
Mal-digestion
Menstrual irregularities
Migraines
Muscle weakness
Mood swings
Nails brittle, break easily
Nails, ridges
Nails, pocked
Nails, white spots
Nausea
Nervous breakdown
Night blindness
Nightmares
Night sweats
Night Terrors
OCD
Oily skin
PMS
Procrastinate often
Need coffee, sugar, or other stimulants to get through the day
Need sunglasses in bright light
Poor digestion
Post nasal drip
Rages
Sensitive to odours, chemicals, or flowers
Seizures
Sinus problems
Skin problems such as acne, rosacea, rashes, dermatitis, eczema, hives, itching, etc. (please specify in the comments section at the bottom of this list)
Sleep disturbances (please specify in the comments section at the bottom of this list)
Sleepy/drowsy during the day
Slow to get going in a.m
Slow to fall asleep at night
Spider veins
Strong body odour
Swelling or puffiness under eyes
Tender breasts
Thin or delicate skin
Thinning hair
Tics
Tire easily
TMJ stress
Tinnitus (ears ringing)
Unable to get pregnant
Unable to maintain pregnancy
Urinate frequently
Uterine fibroids
Vaginal dryness
Weight gain
Weight loss
Comments and details about the above:
Have you had your hearing tested or do you suspect any hearing problems?
*
Yes
No
If yes, please explain.
Have you had your vision tested or do you suspect any vision problems?
*
Yes
No
If yes, please explain.
Have you ever had a serious fall or blow to the head?
*
Yes
No
If yes, please explain.
Have you ever had an accident or any other physical trauma?
*
Yes
No
If yes, please explain.
Have you ever had whiplash or any other musculoskeletal injury or chronic pain such as back pain, stiff muscles, tension, joint pain, etc.?
*
Yes
No
If yes, please explain.
Have you ever used antibiotics?
*
Yes
No
If so, please explain when and for what.
Have you ever been vaccinated?
*
Yes
No
If yes, please indicate how many times and what age and which vaccinations.
Have you ever had a reaction after a vaccine?
Yes
No
Not that I know of
If so, what was the reaction (fever, seizures, loss of language, developmental regression, etc.), how long after the vaccine was administered, how long did it last, and were there any interventions or treatment of the symptoms (such as tylenol, hospitalization, etc.)?
Have you ever had any acute or chronic infection? (Strep, staph, HHV-1, HHV-1, mono/EBV, lyme, bartonella, babesia, SIBO, food poisoning, c-dif, e-coli, salmonella, parasites, measles, rubella, mumps, polio, chicken pox, influenza, parvovirus, coxsackie, hand/foot/mouth, RSV, etc.) List all that apply and when they occurred.
Do you have any implants? Breast, knee replacements, rods, etc.?
*
Yes
No
If yes, please explain.
Have you ever taken HRT (hormone replacement therapy)?
*
Yes
No
In the past
If yes, what for, for how long, and what were the results of the therapy?
(For the Women – Men, just answer “No”): Have you ever taken birth control pills?
Yes
No
In the past
If so, when, for how long, and did you have any noticeable side-effects?
Have you ever been diagnosed with or suspect you have the following? List all that apply.
ADD/ADHD
Alzheimer’s Disease
Allergies (please specify in the comments section at the bottom of this list)
Anemia
Angina
Arthritis (juvenile)
Arthritis (osteo)
Arthritis (rheumatoid)
Asthma
Atherosclerosis
Autoimmune disease - ALS
Autoimmune disease – Crohn’s
Autoimmune disease – Graves’
Autoimmune disease – Hashimoto’s
Autoimmune disease – Lupus
Autoimmune disease – MS
Autoimmune disease – Type 1 Diabetes
Autoimmune – Celiac
Autoimmune disease – Other (please specify in the comments section)
Autism
Bacterial Infection
Blood Clots
Bronchitis
Cancer (please specify in the comments section at the bottom of this list)
Candidiasis, candida overgrowth
Chicken pox
Chronic fatigue (CFS)
Chronic illness (please specify in the comments section at the bottom of this list)
Circulation poor
Cirrhosis
Colitis, mucous
Colitis, ulcerative
Diabetes (Type 2)
Dysbiosis
Ear infections
Endometriosis
Epilepsy
Fungal infections
Epstein Barr Virus
Environmental sensitivities
Fibromyalgia
Food allergies, reactivates, sensitivities (please specify in the comments section at the bottom of this list)
Gall stones
Gastric ulcer
Gingivitis
Glaucoma
Gluten intolerance
Goiter
Gout
GSE–Gluten Sensitive Enteropathy
GSE-Celiac disease, sprue
GSE-Dermatitis herpetiformis
Heart arrhythmia
Heart Disease
Hemochromatosis
Hepatitis
Hiatal hernia
High blood pressure
Heavy metal accumulation
Hypoglycemia (low blood sugar)
Hyperglycemia (high blood sugar)
Hyperthyroid
Hypothyroid
Irritable Bowel Syndrome
Immune depression
Inflammation (without injury)
Inhalant allergies
Insulin resistance
Kidney problems (please specify in the comments section at the bottom of this list)
Kidney stones
Lactose intolerance
Liver toxicity or other problems (please specify in the comments section at the bottom of this list)
Leaky gut
Lung or respiratory problems (please specify in the comments section at the bottom of this list)
Lyme disease
Lyme Co-infection (specify in comments section at bottom of list)
Macular degeneration
Mal-absorption
Mast Cell Activation Syndrome (MCAS)
Metabolic Syndrome
Miscarriage (please elaborate in the section below - how many miscarriages, at what age were you, and at what stage of development)
Mold Illness/Toxicity
Multiple Chemical Sensitivity (MCS)
Muscular Dystrophy
Nutritional deficiencies
Osteopenia
Osteoporosis
Oxidative stress - high free radicals revealed in lab tests
Pancreatitis
Parasitical infection
Parkinson’s
Peptic ulcer
Periodontal disease
Phobias
Pneumonia
POTS
Protein digestion insufficiency
Pyorrhea
Pyrroluria
Sensory Processing Disorder (SPD)
SIBO (small intestine bacterial overgrowth)
Sinusitis
Sleep Apnea
Structural problems, misalignments
Sucrose intolerance
Syndrome X
Tendonitis
Thrush
Tics
Tuberculosis
Tooth infections
Urinary tract infections
Varicose veins
Viral infections (ebv, cmv, herpes)
Yeast infections
Please list additional issues not listed above and note your comments
Have you had any surgeries?
*
Yes
No
If so, when and for what? Please explain.
Do you take any supplements?
*
Yes
No
In the past
If so, please list and indicate if current or in the past.
Do you take any medications (prescription and/or over the counter)?
*
Yes
No
In the past
If so, please list and indicate if current or in the past.
Family Health History: Please list any of the above that members of your family (parents, siblings, and children) have been diagnosed with or have been affected by.
Is there anything else you think I should know? Please use this space to also list any other health concerns or discomfort not included in the questions above.
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Health History timeline
Please find instructions here: https://healthyfamilyformula.com/wp-content/uploads/2018/09/HFF_Creating_a_Health_History_Timeline.pdf (copy and paste into a new browser window).
Maternal Side Health History -Line up all Family Members across from their corresponding condition(s). If you need to make more entries, simply note them in the space below.
More entries for Maternal side
Paternal Side Health History -Line up all Family Members across from their corresponding condition(s). If you need to make more entries, simply note them in the space below.
More entries for Paternal side
Fill in your health history below. Line up all information with the event being reported. Make notes for ages 0-10 in section 1; 11-20 in section 2, 21-30 in section 3, 31-40 in section 4, 41-50 in section 5, 51-60 in section 5, and 61 and on in section 6. Separate each entry with a semi colon.
Type a question
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Final Thoughts
We have left the most important questions for last, so do take the time to think about your answers.
Please list your top five health concerns – the things that you want to address first and that bother you the most.
*
Have you seen any other practitioners and/or doctors about the above?
*
Yes
No
If so, can you tell me what kind of practitioner and/or doctor you saw (ex. Chiropractor, medical doctor, endocrinologist, massage therapist, yoga instructor, acupuncturist, etc.), what your experience was, and what advice and or diagnoses you were given?
What therapies/protocols are you doing right now?
What therapies/protocols have you tried in the past? What was your experience with them - successful, detrimental, not effective or no change?
Are you finding any success? Setbacks?
Your Why
What is health? Define health in your own words.
Sit for a few minutes and tell me why you want to get you and/or your family healthy.
Tell me what the most difficult issues you have that block you from becoming healthy.
On a scale of 1-10, how dedicated are you to doing what it takes to regain your health and vitality?
1
2
4
7
8
9
10
What are the first things you are going to do when you start feeling better?
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Early Beginnings
Answer the following questions if you are filling this out for your child or teen, AND if you are filling this form out for yourself, please complete the sections you know the answers to about your own birth.
Would you consider mom’s pregnancy healthy?
Yes
No
Why or why not?
What did mom eat and drink during her/your pregnancy? Any unusual cravings?
Did mom take any medications during her/your pregnancy?
Yes
No
If yes, please list.
Did mom receive any vaccinations during her/your pregnancy?
Yes
No
If yes, which ones?
Did mom experience any trauma during her/your pregnancy?
Yes
No
If yes, you can describe if you are comfortable doing so.
How was mom’s stress level during her/your pregnancy on a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
Please elaborate (work, home life, finances, lifestyle, etc.)
Did mom have any infections or surgeries during her/your pregnancy?
Yes
No
If so, please elaborate.
Does mom have amalgam fillings or had some in the past and had them removed?
Yes
No
In the past
If so, for how long and/or when were they removed?
Did mom use or was exposed to any other toxins during her/your pregnancy?
Yes
No
Type a question
Please describe your child’s birth. Include interventions, medications, ease, stress level, complications, your feeling during the event, natural birth or hospital, midwife or doula, length of labor, early birth or late, etc. Please include anything else that comes to mind.
Feel free to use this space to include additional info that I have not asked about. Again, please consider filling out an intake form for yourself (optional) to add even more valuable information to help with your child’s health recovery. Thank you for taking the time to complete this intake process. You are truly a revolutionary parent!
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HFF Scope of Practice Client Waiver
Please read the following and indicate that you have read and understand the terms of service before your Intake Form will be accepted. Read here (cut and paste into a new window): https://healthyfamilyformula.com/wp-content/uploads/2019/07/HFF-Scope-of-Practice-Client-Waiver.pdf
Client Declaration: I have read and understood my practitioner's scope of practice and the terms of the HFF client waiver.
*
Yes
Please sign here
OK, you’ve made it! Congratulations on taking this step toward lasting health and renewed vitality!
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