Nutrition Intake Form

Full Name

First NameLast Name

Preferred Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

Confirmation Emailexample@example.com

Preferred Contact Method

Other

Birth Date

MonthDayYear

Patient Birth History

What is your Gender?

Other

Blood type

Genetic Heritage

Family Medical History

Rows	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
Inflammatory arthritis
Obesity
Osteoporosis
Pitting edema
Psoriasis
Varicose veins

Family Medical History

Rows	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
Cancer
Heart Disease
Hypertension
Non-alcoholic fatty liver disease
Type I Diabetes
Type 2 Diabetes
Stroke

Family Medical History

Rows	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
ALS or other motor neuron diseases
Dementia/Alzheimer's disease
Graves' disease (hyperthyroidism)
Hashimoto's disease (hypothyroidism)
Multiple Sclerosis (MS)
other Autoimmune diseases (i.e. lupus)

Family Medical History

Rows	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
Asthma
Celiac disease
Crohn's disease
Eczema/Psoriasis
Food Allergies/sensitivities
Environmental sensitivities
Inflammatory Bowel disease (IBD)
Irritable Bowel Syndrome (IBS)

Family Medical History

Rows	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
ADD/ADHD
Autism
Bipolar disorder
Depression
Psychiatric disorder(s)
Schizophrenia

I am currently experiencing the following conditions...

Hi There! Great work so far! A quick heads-up about the next portion. The "Personal Medical History" section requires selecting either acute, chronic, past, present, or both, in reference to medical conditions you currently may be experiencing or have in the past. Please be honest and only select the conditions that apply to you, specifically. Thank you for your time and effort and Remember to be Your Best Friend and Advocate Always! Happy Healing

Personal Medical History

Female Medical History

Male Medical History

Personal Dental History

Are you currently taking any medication?

Medication History

Medication and Vitamin List

Do you have any medication allergies?

Do you use or do you have history of using tobacco?

Do you use or do you have history of using illegal drugs?

How often do you consume alcohol?

What did you eat today?

On average, I sleep...

On average, I exercise...

Occupation/Job Title

Please include any specific physical demands needed to perform job

Please list any significant physical trauma you've experienced:

Please list any emotional trauma you've experienced in your life:

When was the last time you felt well?

Did something prompt your change towards health and wellness, in the past and/or recently? Please list and give a brief description for each item listed.

Please list Your Wellness Goals

What is Your Why?

Please upload any other documents you see necessary to achieve your health and wellness goals.

Browse Files

(i.e. lab tests, medical files, medication list...)

I have done my best to be truthful, comprehensive and complete with my answers to the best of my ability and knowledge. I understand and agree that this confidential information of my medical and health history will be maintained by Healing Plate, and will not be released to any individual except when I have authorized this release in writing.

E-Signature

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