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

Phone callEmailTextOther
Birth Date*

MonthDayYear
Patient Birth History*

Vaginal deliveryC-sectionFull termPrematureBreast fedBottle fedUnknownOther
What is your Gender?*

MaleFemaleOther
Blood type*

ABABORh+Rh-Unknown
Genetic Heritage

African AmericanAsianCaucasian/EuropeanHispanicNative AlaskanNative IndianNative Hawaiian and other Pacific IslanderOther

Family Medical History

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

Family Medical History

	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

	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

	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

	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...*

Cardiac diseaseCardiovascularChest painDiarrheaForgetfulnessGastrointestinal distressGenitourinaryHematological (blood)LymphaticNeurologicalPsychiatricRespiratoryWeight gain, unexplainedWeight loss, unexplainedMusculoskeletalRegurgitation, unexplainedRestless/Restless LegSleeplessness/InsomniaVertigo (dizziness)Other
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
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Female Medical History
Female Medical History
Female Medical History

EndometriosisFibrocystic breastsFibroidsHeavy menses (periods)InfertilityPainful mensesPMDDOther
Female Medical History

Gestational DiabetesFull-term pregnancyPre-term pregnancyPostpartum depressionToxemiaBaby over 9 poundsPMDDOther
Female Medical History

Concentration/Memory issuesDecreased libidoDifficulty sleepingHeadachesHot flashesLoss of bladder/urine controlMood SwingsPalpitationsWeight gainVaginal drynessOther
Male Medical History

Change in libidoDifficulty obtaining an erectionDifficulty maintaining an erectionFrequent urination at nightImpotenceLoss of urine controlProstate enlargementProstate infectionUrgency/Hesitancy/Stream chg.Other
Personal Dental History

Bleeding gumsFloss regularlyGingivitisGold fillingsImplant(s)Root canal(s)Silver Mercury fillingTooth painOther
Are you currently taking any medication?*

YesNo
Medication History*
Medication History*
Medication History*
Medication History*
Medication History*
Medication History*
Medication and Vitamin List
Do you have any medication allergies?*

YesNoNot Sure
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?*

DailyWeeklyMonthlyOccasionallyNever
What did you eat today?
On average, I sleep...*

8 hours/night, uninterrupted8 hours/night, interrupted5-7 hours/night, uninterrupted5-7 hours/night, interrupted3-4 hours/night, uninterrupted3-4 hours/night, interrupted1-2 hours/night, uninterrupted1-2 hours/night, interruptedInsomniaOther
On average, I exercise...*

5-7 days a week for at least 30 minutes2-4 days a week for at least 30 minutes1 day a week for at least 30 minutesOccasionallyRarelyNever
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...) Cancelof
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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Please verify that you are human*
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