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Initial Consultation Form
(This form is private, and will only be reviewed by your consultant.)
Full Name:
First Name
Last Name
Age:
Sex:
Male
Female
Other
Email
example@example.com
Phone Number
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Area Code
Phone Number
Please list your three top health concerns in your order of importance:
What are you hoping to get out of your nutritional consulting experience?
Does anyone in your family have any illnesses? Please explain:
Have you ever received any diagnoses? Please explain:
Are you having any symptoms that are concerning to you? Please share:
Do you have any symptoms that keep you from functioning well on a daily basis? Please describe:
How would you describe your health?
How would you describe your energy?
Do you frequently get sick? Please explain:
What forms of movement/physical activity do you do?
How would you describe your relationship with food?
Do you feel like you get enough to eat?
Do you ever skip meals or fast?
Do you feel thirsty often?
Do you have any food cravings?
Do you ever get bloated when you eat? If so, please describe here:
Do you have an appetite when you wake up in the morning?
When do you usually wake up in the morning?
When do you usually go to sleep in the evening?
Do you ever wake up hungry in the middle of the night?
How often do you eat during the day?
How would you describe your skin, hair, and nails?
Are you currently pregnant or trying to conceive?
Please describe your experiences with menstruation over the years:
How many alcoholic beverages do you consume per week?
How many times do you eat out per week?
How many caffeinated beverages do you consume per day?
Do you use Cannabis? What forms? How often?
Please list any other relaxants, stimulants, hallucinogens, narcotics, or other substances you use:
How many times a week do you eat fish?
How many times a week do you eat raw nuts or seeds?
Do you smoke?
Please Select
Yes
No
If yes, how many times per day?
How many times per week do you workout?
Please list all supplements and medications you are currently taking and for what conditions:
Do you have any known food allergies or sensitivities? Please list:
Do you experience acid reflux?
Please detail any surgeries or procedures you've had:
Is there anything keeping you from being healthy? Please explain here:
How long do you think it will take you to feel better?
One Week
One Month
Six Months
One Year
Other
Do you have any Reports/Notes/XRays you would like your consultant to preview?
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Initial Intake Consultation
$
225.00
This intake information is reviewed by your consultant at Next Ingredient in preparation for your first consultation, which is a 60-minute intake visit.
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