Client Intake Form
REID Program
Client Name (Please fill out questions relative to this person)
Client Age
Client Location (US State or Country)
Name of Parent (1) if client less than 18 years
First Name
Last Name
Name of Parent (2) if client less than 18 years
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
How did you hear about the REID Program
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Part II: Family History
Client lives with:
Both Parents
Mother
Father
Spouse
Single
Other
Other Children In Family
Name
Age
Health Concern (if any)
Name
Age
Health Concern (if any)
Name
Age
Health Concern (if any)
Name
Age
Health Concern (if any)
Health History
Were there any notable issues with the mother's health during pregnancy (infections, colds, immune responses)
Any particular notes about pregnancy or birth?
When did you first become concerned with health?
Did client experience any developmental delays?
Yes
No
If yes, describe developmental delay and age of onset.
Was client ever on antibiotics before the age of 2?
Yes
No
Not sure
Did client experience any recurring infections at a young age? (ear, respiratory, etc)
Has client ever experienced an immune activation event that resulted in a negative longterm impact on health? Examples include- high fever, illness after travel, vaccine reaction, infection (bacterial, viral, fungal), surgery, physical injury, persistent skin rashes, life stress event (new sibling, car accident, moving, etc.) or other immune activation event?
Yes
No
Not Sure
If yes, please describe event and age at the time.
Was there regression in development following this immune activation event? If yes, please describe.
Is client currently or recently under physicians care?
Yes
No
If yes, why?
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Part III: Health Concerns
Describe the health concerns you have at this time
Has this health concern resulted in a medical diagnosis?
Any additional health concerns/issues in family?
Symptoms
Please Rate the following health issues/symptoms:
Rows
None
Mild
Moderate
Severe
Not sure
Seizures
Tics
Hyperactivity
Anxiety
Depression
Stimming
Agression
Speech Delay
Sleep Trouble
Obsessive Thoughts
Sensory Issues
Grinding Teeth
Joint Pain
Eczema/Skin Issues
Defiance
Low Muscle Tone
Picky Eating
Cravings
Migraines/Headaches
Bloating
Darkness Under Eyes
Brain Fog
Low Energy
Stomach Pain/Gas
Restrictive Eating
Over Eating
Always Hungry
Restless Leg
Food Allergies
Environmental Allergies
Please rate the following information based on bowel movements:
Rows
None
Mild
Moderate
Severe
Constipation (fewer than 1 BM/Day)
Diarrhea
Undigested Food in Stool
Floating Stool
Sandy Gritty Stool
Very Smelly Stool
Green Color in Stool
Pale Yellow Color in Stool
Red Color in Stool
Please note any known specific food allergies/sensitivities
Food Intake
Over the past 3 month how would you rate your overall diet
1
2
3
4
5
Bad
Fantastic
1 is Bad, 5 is Fantastic
Please list any foods you are eliminating at this time.
Which best describes your typical meal? (BREAKFAST)
Green smoothie with whole foods
Whole food protein like eggs, nuts, seeds, whole milk yogurt (no additives)
Whole grains like steel cut oats, quinoa
Cereals, sweet baked goods, pancakes/waffles, yogurt with fruit or added sugar
Breakfast meats like bacon, sausage and ham
Breakfast drink with powdered proteins and vitamins
Don’t eat breakfast
Other
Which best describes your typical meal? (LUNCH)
Homemade salad with whole food ingredients, whole foods like nuts, seeds, fruits
Homemade lunch(not sandwich)
Homemade sandwich
Readymade lunch (like microwave meals, soups, Lunchables)
Go out to lunch most of the time
Don’t eat lunch
Other
Which best describes your typical meal? (DINNER)
Homemade meal with whole fresh food ingredients with majority of vegetables
Homemade meals with whole fresh food ingredients with some premade items like sauces, dressings, and condiments
Pastas, breads, white rice, canned foods, cheese as the majority
Premade meals like pre-seasoned rice, frozen meals, soups
Go out to dinner most of the time
Don’t eat dinnner
Other
Which best describes your typical meal? (SNACK)
Whole foods like raw nuts, seeds, fruits, vegetables, boiled egg
Cheese
Prepackaged snacks like chips, trail mixes, granola/protein bars, crackers
Candy, sweet baked goods
Don’t snack
Other
What percentage of your diet would you estimate comprises factory-processed foods? (Include canned food, pre-made meals, packaged foods with multiple ingredients, cheese, bread, cereals, and eating out)
0-5%
6-15%
16-25%
26-35%
36-45%
Greater than 46%
How many servings (1 cup) of non-starchy vegetables? (exclude corn, peas, potatoes, sweet potatoes, and squash)
More than 5 servings /day
3-4 servings/day
1-2 servings/day
3 servings/ week
1 serving/week
Less than 1 serving/week
Other
Which of the options best describes your most abundant source of protein.
Vegetables, nuts, seeds
Legumes (beans, lentils)
Meats (not factory processed), eggs
Dairy
Protein enriched products like protein powders, protein bars, cheese substitutes
Meat substitute products like tofu and veggie burgers and processed meat like lunch meat, smoked meats, and sausage
Premade meals with combination of meat dairy, and other sources of protein
Other
How often do you eat out at a restaurant or take out?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
How often do you eat at a fast food restaurant?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
How often do you drink milk (or non-dairy milk) as a beverage?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
How often do you eat cheese or cheese product?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
Over the past 3 months, how often did you drink meal replacement or high-protein beverages (such as Protein Powder, Instant Breakfast, Ensure, Slimfast, Sustacal or others)? How often do you eat cheese or cheese product?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
How often do you eat wheat?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
How often do you consume juice and soda do you consume per week?
1
2
3
4
5
Never
Often
1 is Never, 5 is Often
How many servings of fruit do you consume per day?
1
2
3
4
5
Servings
1 is Servings, 5 is
What kind of milk do you usually drink?
Raw milk
Homemade non-dairy milk (like coconut, rice, nut & seed)
Whole milk
2% fat milk
1% fat milk
Skim, nonfat, or ½% fat milk
Commercial Non-dairy milk (like coconut, rice, nut & seed)
None
What is your most common source of grain?
Whole grains like black, brown, and red rice, quinoa, steel cut oats, and bulgur
White rice, rolled oats
Pasta
Cereals
Breads
Other
What kind of milk do you usually drink?
Raw milk
Homemade non-dairy milk (like coconut, rice, nut & seed)
Whole milk
2% fat milk
1% fat milk
Skim, nonfat, or ½% fat milk
Commercial Non-dairy milk (like coconut, rice, nut & seed)
None
Which option best describes your intake of sugar in your diet?
Minimal amount of fruit and no refined sugar
Modest amount of fruit and no refined sugar
Minimal amount of refined sugar and fruits
Most of my food options contain natural or enriched sugar
Is there anything of note or special about your diet?
Please list current supplements in diet. (Brand and product name)
Intervention
What actions do you feel have improved health thus far?
Do you believe healing is possible?
What are some questions you have?
What would you most like to gain from our meetings?
If you would like any lab results to be reviewed for food considerations, please submit. (urine, blood, stool, hair test results)
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We look forward to being part of your healing journey!
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