Client Information
Name
First Name
Last Name
Date of Birth
 -
Year
 -
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
How did you hear about us?
Google
Friend
Instagram
Family
Facebook
Silver Fern Brand
Cleint Overview
Height
Weight
Body Fat %
Desired Weight
Biggest health frustration?
When did symptoms begin?
What triggered this (stress, illness, antibiotics, pregnancy, diet change, etc.)
Have symptoms worsened, improved, or stayed the same?
What is it that you want to accomplish?
Gain Muscle
Lose Weight
Increase Energy
Restore Gut Health
Improve Physical Fitness
Improve Metabolic Health
Optimize Hormone Health
Have you worked with any of the following
Nutritionist
Personal Trainer
Health Coach
Acupuncturist
Chiropractic
Functional Doctor
Lifestyle & Nutrition
What time do you wake up
Hour Minutes
AM
PM
AM/PM Option
What time do you go to sleep
Hour Minutes
AM
PM
AM/PM Option
Stress level (0-10)
What are your main stressors
Sleep quality (bad 0-10 great)
Sample exercise routine
What time do you workout
Hour Minutes
AM
PM
AM/PM Option
How long are your workouts
Hour Minutes
What time is your first meal
What time is your last meal
How many meals per day do you eat
How many snacks per day do you eat
Do you get bloated after a meal
Yes
No
How many bowel movements a day
How many oz of water do you drink daily
Favorite Macronutrient: Pick one
Protein
Carbs
Fats
Which cooking oils do you use
Coconut Oil
Avocado Oil
Olive Oil
Vegetable Oil
Ghee Butter
Regular Butter
Tallow
Please list all animal products you dislike
Please list all fruits and vegetables you dislike
Pleaae list all grains & legumes you disline
Please list all nuts and seeds you dislike
Please list all supplements you are taking
What are your favorite foods, snacks and drinks
Please list a sample of your daily meals
Breakfast
Lunch
Dinner
Snacks
Medical History
Diagnosed conditions?
Yes
No
Please explain
Have you had surgeries before?
Yes
No
Please explain
Are you taking medications?
Yes
No
Please explain
Do you have a thyroid condition?
Yes
No
Please explain
Are you on hormone therapy or birth control ?
Yes
No
Please explain
Nervous system state
Irritable
Anxious
Depressed
Burned out
Good
Do you have a history of the following?
IBS
SIBO
Parasites
H. Pylori
IBD (UC/Crohn's)
Candida/fungal overgrowth
Antibiotic use (more than 1 round)
No
Kidney Stones
Yes
No
Kidney Disease
Yes
No
Urinary Infections
Yes
No
Urinate at Night
Yes
No
Swollen Feet or Hands
Yes
No
Gallbladder Stones
Yes
No
Liver Disease
Yes
No
High Cholesterol
Yes
No
Heart Disease
Yes
No
Teeth Grinding
Yes
No
Lower Back Pain
Yes
No
Health Assessment
GUT DYSFUNCTION
Rows
0 - none
1 - mild
2 - moderate
3 - severe
Gas
Bloating
Constipation
Diarrhea
Reflux/Heartburn
Abdominal pain
Nausea
Food sensitivities
Undigested food in stool
IBS diagnosis
History of antibiotics
Sugar cravings
HORMONE IMBALANCE
Rows
0 - none
1 - mild
2 - moderate
3 - severe
Fatigue
Brain Fog
Mood Swings
Low Libido
Poor Sleep
Hair Thinning
Cold Intolerance
Weight Gain
Low Motivation
Irregular Cycles
PMS/Irritability
Erectile Dysfunction
METABOLIC HEALTH (BLOOD SUGAR / MITOCHONDRIA)
Rows
0 - none
1 - mild
2 - moderate
3 - severe
Sugar Cravings
Energy Crashes
Belly Fat
Difficulty Losing weight
Brain Fog
Frequent Hunger
Shaky When Hungry
Fatigue After Meals
High Triglycerides
High Fasting Glucose
Low Energy For Workouts
Afternoon Crash
NERVOUS SYSTEM
Rows
0 - none
1 - mild
2 - moderate
3 - severe
Sugar Cravings
Energy Crashes
Belly Fat
Difficulty Losing weight
Brain Fog
Frequent Hunger
Shaky When Hungry
Fatigue After Meals
High Triglycerides
High Fasting Glucose
Low Energy For Workouts
Afternoon Crash
TOXIC LOAD (HEAVY METALS / MOLD)
Rows
0 - none
1 - mild
2 - moderate
3 - severe
Mold Exposure
Water Damage Home
Chemical Sensitivity
Reactions to Supplements
Headaches
Skin Rashes
Fatigue
Sinus Issues
Brain Fog
Metallic Taste
Joint Pain
Night Sweats
Submit
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