Client Intake Forms

Client Intake Forms

Please complete and submit prior to your appointment.
Today's Date

MonthDayYear
Date
Name

FirstLast
Age and Date of Birth
Email
example@example.com
Cell Number
Please enter a valid phone number.
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nutritional Data: How many ounces of water do you drink PER DAY? What kind of bottle?
What other beverages and how much?
Do you drink coffee? If so, how often and how much?
Do you drink alcohol? If so, how much and how often?
Do you smoke? If so, how much and how often?
Do you use artificial sweeteners? if so, which ones?
Do you eat breakfast? If so, what do you eat?
How much of the following do you consume? (Example 1D = 1/day, 2W = 2/week, 3M = 3/month
Fresh Fruit
Amount
Raw Vegetables
Amount
Bread
Amount
Fermented Foods (Kombucha, Sauerkraut, Keifer)
Amount
Fast foods
Number of day per week?
Meat
Amount
Eggs
Amount
Dairy
Amount
What foods do you crave?
What foods do you like and dislike the most? And why?
Timing:
What is the first thing you do when you get up in the morning?
What time do you eat your first meal? What time do you eat your last meal?
Which meal is your largest of the day? Describe what that typically looks like.
Movement: Do you exercise/move/participate in a sweaty activity? If so, what, and how often?
Do you look forward to it?
How do you feel when you are finished?

Sleep: What time do you go to bed? How long do you typically sleep?
Do you wake often? If so, why and at what time(s)? Do you feel rested when you wake up for the day?
Do you have pain when you first get up? If so, where? Does it go away upon moving?
Eliminations: Do you have daily bowel eliminations? If yes, how many per day? If no, please describe your elimination pattern.
Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided BSC #
For Females Only: (If Male, skip to: "Do you take Supplements or Medications? Yes Or No?"): Are you post-menopausal? If yes, what age did you enter menopause? What were the characteristics of your menopausal experience?
Do you currently use Hormone Replacement (HRT) or Hormonally based Contraception?
Are you now, or in the near future, planning to become pregnant?
Menstruation: Is your menstrual cycle regular? What is its average duration? (Longer or shorter than 28 days?)
Do you have cramps or clotting? Would you describe the typical color of your menses as bright red, dark purple, or brown?
Do you take Supplements or Medications? Yes Or No?

Only SupplementsOnly MedicationsBoth
If you take supplements, what kind and how often?
If you take OTC medications routinely (such pain reliever or allergy medicine) what kind and how often?
If you take prescription medications routinely (prescribed by licensed medical professional) what kind and how often?

Client Disclaimer

We are not a medical doctor. I am Board Certified Naturopathic Doctor. I do not prescribe medication. I recommend natural holistic supplementation, and modalities. I understand that Lisa Carr and anyone acting on behalf of EssentialWellness Advantage, LLC, may provide nutritional suggestions and other health-related information, based on their holistic training, knowledge, experiences, and understanding, to help me attain my personal best health. All recommendations are designed to help me keep and enjoy my best state of health through personalized recommendations in lifestyle, exercise, health habits, and nutritional habits. I understand that Lisa Carr and anyone acting on behalf of EssentialWellness Advantage, LLC, do NOT ever attempt to diagnose, treat, cure, or claim to cure cancer, sickness, or any other disease. We address the total health of the person.
I understand and agree (please type full name)
Client Signature

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GETTING TO KNOW YOU...Before your Zyto Balance/Elite scan!

Welcome...please fill out this form to the best of your ability. If you get stuck, don't worry...we will review this form together. We will utilize this information in your consultation. Relax...you are in the right place.
What is your occupation?
Did you hear about us?

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We apologize in advance for the legal jargon which follows. We live in a crazy time, where the pressure of government, economic, and legal agencies weigh heavily on those working to provide quality, natural healthcare. Please read the informed consent below and sign to acknowledge your understanding. If you have any questions, please feel free to ask!
I acknowledge that Dr. Lisa Carr (BCND) and anyone acting on behalf of Essential Wellness Advantage, LLC, are not medical doctors. I understand that Lisa Carr and anyone acting on behalf of Essential Wellness Advantage, LLC, may provide nutritional suggestion and other health-related information, based on their knowledge, experiences, and understanding, to help me attain my personal best health. All recommendations are designed to help me keep and enjoy my best state of health through personalized recommendations in lifestyle, exercise, health habits, and nutritional habits. I understand that Dr. Lisa Carr (BCND) and anyone acting on behalf of Essential Wellness Advantage, LLC, do NOT ever attempt to diagnose, treat, cure, or claim to cure cancer, sickness, or any other disease. I have read this informed consent, and I understand it. I am not a minor. (If scanning for someone under the age of 18, please give parental signature below.) Additionally, I am here on this day and any subsequent visit, solely on my own behalf and not as an agent for any federal, state, or local agencies on a mission of entrapment or investigation, and I also certify that I am signing my own true given, legal name and not an alias or false name.
Client signature

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Dr. Lisa Carr, BCND, BCDNM, CHS, CHHP, CNHP – 678-769-7070
(Essential Wellness Advantage) 4482 Commerce Dr. Ste. #201 Buford, GA 30518
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