Client Intake Form ED

Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Post codeCountry
Date of Birth*

DayMonthYear
Place of Birth (Town/City & Country)
Sex

MFIntersexTransgender
E-mail*
Phone Number*

Area CodePhone Number
Do you wish to receive our monthly e-newsletter containing free recipes, videos, special offers, events & more?

YesNo
If you are completing this information on behalf of someone else please provide your name, relationship to the client, and your contact details.
How did you find out about Funky Forest Health & Wellbeing?*
What type of therapy are you seeking?*

NaturopathyDietetic & Nutritional TherapyEating Disorder Therapy
Is your request to see a specific therapist? If so, who?
Click to select, or leave blank if n/a
Have you been referred to our practice by another health professional? If so, please provide their name.
Is your availability to attend appointments limited? If so, please note your general availability here. (Please be aware that our after hours availably is limited and may require a longer waiting time for an initial appointment).
Occupation (what are you doing in life and are how do you feel about it?)
Who do you live with?
Emergency Contact Name
Emergency Contact's Phone Number

Area CodePhone Number
Emergency Contact's Email
example@example.com
Do you have a regular Medical Doctor (GP)? If so, please provide their name
GP's Phone Number

Area CodePhone Number
Do you have a regular Psychologist? If so, please provide their name
Psychologist's Phone Number

Area CodePhone Number
Are you under the care of any other health professionals? If so, please provide their names and professions
I give my clinician at Funky Forest Health & Wellbeing permission to speak with and disclose my protected health information with the above-named treatment providers.

YesNo
Signature

Clear
Date

DayMonthYear
Date
Purpose of our Consult
Tell me about why we are meeting. What do you feel is the primary purpose?*
Biometrics
You can leave any of these blank if you prefer, we can discuss it in session together.
Height (cm)
Current Weight (kg)
Body Mass Index (if known)
If you are currently under your healthy weight range, and you are seeking therapy for an Eating Disorder please note your current BMI above (or your height and weight here), and any medical concerns. (This information is required as we are not able to accept referrals from clients with a very low BMI or who are medically compromised)
Average weight for the past 2 to 3 years?
Weight you feel most comfortable
When were you last at that weight?
Highest adult weight & age?
Lowest adult weight & age?
Have you lost or gained weight recently? If so, how much, and in what time frame?
Do you weigh yourself currently? If yes, how frequently
If applicable: Pre-pregnancy weight, and weight gained with pregnancy?
Please select how you currently feel about your body

Strongly dislikeDislikeSlightly satisfiedSatisfiedVery satisfied
Family History
Relationship status
If applicable: partner's name and age
Children?

YesNo
If Yes, how many and ages?
Share with me any family dynamics you feel are important for me to know/understand.
What was food like in your house growing up? What is it like now? Does anyone in your family have a history of dieting, disordered eating, or eating disorders? Other chronic illnesses?
Family history health issues (circle all that apply, going back to grandparents)
If other, please describe:
Food & Nutrition
Tell me about your dieting and/or your eating disorder history.
How many meals a day do you eat?
Do you skip meals? If yes, which ones do you skip and why?
What are your snacking habits (i.e. frequency, time of day, foods you choose)?
How many meals per week do you eat at a restaurant?
Which restaurants do you normally choose?
How does your meal and snack pattern vary on the weekend vs. during the week?
When you feel overwhelmed or life gets busy, do you neglect your eating habits? If yes, please describe.
Do you feel that your life/schedule conflicts with nourishing your body in the way you’d like to? If yes, please describe.
Do you eat and multi-task (i.e. read, watch TV, drive) If yes, please describe.
Where do you eat your meals?
Do you feel you eat particularly fast or slow? If yes, please describe.
Do you cook?

YesNo
Do you know how to cook?

YesNo
Who does the grocery shopping?
Who prepares the food at home?
Do you read food/nutrition labels? If yes, what do you look for on labels?
Do you travel and/or entertain for business? If yes, how often?
Food Intake

Please list the usual time and typical daily intake for each meal:
BREAKFAST
LUNCH
DINNER
SNACKS
What foods do you love?
What foods do you dislike?
Are there any foods that feel like binge foods for you?
Are there any foods that feel “safe” to you?
Does your diet have a lot of variety or does it tend to be the same from day to day?
Digestive Health
Have you ever received a gastrointestinal (GI) diagnosis? If yes, please describe.
Did you have any GI issues as child or adolescent? If yes, please describe.
Are there significant GI issues in your family? If yes, please describe.
Please check any of the following for which you have been tested:

Coeliac testing (done by duodenal biopsy)Lactose intolerance breath testFructose malabsorption breath testSIBO breath testThyroid levelsVitamin D levelAllergy or food intolerance testing
Comments on any of the above e.g. type of allergy or intolerance testing, IgE/RAST test or IgG; if SIBO breath test. Were methane and/or hydrogen measured separately? Results, etc:
Do you have any food allergies?
Have you been tested for food allergies? If yes, please list:
Do you have any food intolerances?
Have you been tested for food intolerances? If yes, please list:
GI Procedures/Testing: Please circle testing you have completed and in comments section, note any abnormal results or findings. If possible, include the date of the study.

pH monitoringEndoscopyOesophageal manometryGastric emptyingDefocographySitzmark StudyColonoscopyAnorectal manometry
Elimination Patterns

On a scale of 1-10 (10 = terrible, 1=non-existent) please state a number that identifies the level intensity of the following symptoms:

Gas

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Nausea

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Constipation

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Diarrhoea

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Reflux / (GORD)

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Bloating

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Abdominal Pain

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Dysphagia

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Incomplete emptying

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Faecal Incontinence

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Systemic Symptoms

On a scale of 1-10 (10 = terrible, 1=non-existent) please state a number that identifies the level intensity of the following symptoms:

Fatigue

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Anxiety

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Problems with sleep

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Skin itch

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Urticaria (hives)

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Dry eyes

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Swollen lips/blistering

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Atopic dermatitis

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Based on the above symptoms, how frequently during the week or month do your symptoms impact your quality of life?
Exercise & Activity
Have you ever had a consistent exercise routine? If yes, tell me about your past exercise habits/relationship to exercise.
Are you following an exercise routine currently? If yes, please describe
Tell me how you feel about exercise
Is there anything else you want to share regarding your relationship to exercise?
Reproductive Health (for womxn)
First Menstrual Period (Age)
Are you currently getting your period?

YesNo
Have there been any inconsistencies with your menstrual cycle? (e.g. missing periods, regular or irregular, cycle length (in days), difficult, heavy clotting, painful)
Number of Pregnancies (Please indicate if full-term)
Please state if you are peri- or post-menopausal, and what age you reached menopause if applicable
Personal Health & Medical History
Please list/describe any medical diagnoses or procedures I should be aware of.
Please list your current medications & supplement dosages
What are your major sources of imbalance?

WorkSchoolRelationship(s)FamilyHealth IssuesFinancesOther
Comments on any of the above?
Please list/describe any mental health concerns should I be aware of (i.e. depression, anxiety, OCD, PTSD)?
Please share any illicit drug, alcohol, cigarette use
Rate your health

ExcellentGoodFairPoor
What is your general energy level most of the time?

Rate your current perceived level of stress on a scale of 1-10?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

Sleeping habits (Total and Quality)

On a scale of 1-10, 10 being the highest, how much support do you need when making lifestyle changes?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

Do you have a strong support system? Please describe.
Have you ever been advised by a health practitioner to follow a special diet? (i.e. low salt/cholesterol, no sugar, paleo, keto, etc.) If yes, what changes did you make at that time?
Have you ever worked with a dietitian/nutritionist? If yes, tell me about your experience
What types of social media do you use?
How do you feel social media affects you?
Which of the following most describes your thought pattern?
Comments on above thought pattern?
Hospitalisations/Surgery: Please provide month/year with brief description.
Recent significant biomedical results / blood pathology in last 3 months (e.g. Cholesterol, HbA1c, Fasting Blood Sugar)
Optional: Feel free to upload any blood or other results you think I need to have before our first consultation:

Browse Files

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Your Goals
What do you hope to accomplish through our first visit?
What are your short-term goals?
What are your long-term goals?
Please feel free to share any additional information here.
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Biometrics

Family History

Food & Nutrition

Food Intake

Digestive Health

Exercise & Activity

Reproductive Health (for womxn)

Personal Health & Medical History

Your Goals