Consultation Request Form

Initial Health Information & Goals
What is your primary health concern(s) or health goal(s) you are seeking nutritional support for? For example: skin problems (acne, eczema, etc), stomach pain, chronic fatigue, weight loss, allergies, or anything else similar. Please list only your main concern(s):
How long have you been experiencing the main issue(s)?
Have you noticed any dietary or lifestyle patterns with regards to the issue(s)? For example, "my skin flares up with certain foods", or, "I feel the most tired in the afternoon at 2pm".
Have you ever had any gastric or abdominal surgeries? For example: gastric bypass, gallbladder removal, a section of bowel removed or repaired, etc.?
- If yes to the above question, when was your procedure are you still being treated in any way for the procedure(s) or complication(s)?
-Are there any specific doctor's recommendations with regards to changes in diet and/or lifestyle?
Have you been diagnosed with any type of autoimmune disease(s)?
i.e., Hashimoto's thyroiditis, Rheumatoid arthritis, Type 1 diabetes, Multiple sclerosis, etc.
Have you ever been on a nutritional/lifestyle program, diet plan, or regimen before?
i.e., Keto diet, Atkins diet, fasting protocols, vegetarian, gluten-free, etc
Would you be willing to try dietary recommendations and/or substitutions?
Would you be willing to try lifestyle recommendations and/or substitutions?
Do you have any known or diagnosed food allergies? Please list:
i.e. peanuts, gluten, dairy
Do you have any suspicions of food, beverage, or topical sensitivities that gives you an upset stomach, skin rash, or any other similar issues?
i.e. dairy makes my stomach upset, a type of topical cream gives me a rash
Do you have any known environmental or pet allergies?
i.e. runny nose/itchy eyes in spring and summer, pet dander allergy, pollen, etc.
Are you taking any prescription medications? If comfortable with sharing, please list the medication name(s) and dose(s). This is to ensure that none of the possible recommendations will interfere with the normal functioning of the medications.

Terms & Agreements
Newfound Nutrition Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Your scheduled session is set aside for you. There are no double-booked appointments

       • Please call/contact and reschedule your session if you are more than 15 minutes late

       • Clients may be subject to a fee for cancellations with less than 24 hours notice

       • You will have a consultation with your nutritionist to discuss your assessment

       • I understand that my nutritional consultant or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Nutritional Client Agreement:

I hereby attest to the following:

I understand that holistic nutritional consultants do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals.

The services provided by Newfound Nutrition are at all times restricted to consultation on the subject of nutritional matters intended for general nutritional well-being and do not involve the diagnosing, prognostication, or prescribing of remedies for the treatment of any disease or any licensed or controlled act which may constitute the practice of medicine in your province.

I acknowledge that nutritional changes are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive nutritional and lifestyle assessments and recommendations as a form of supplemental care toward my own health goals.

I understand that the recommendations given are designed to address my primary health concerns.

I have stated my pertinent medical conditions and will update the registered holistic nutritionist of any changes in my health status.

I understand that my failure to do so may pose a threat to my health and/or physical well-being and I do not hold Newfound Nutrition and my Registered Holistic Nutritionist liable whatsoever arising from failure on my part.

I am of proper age (16 years and older) for a nutritional and lifestyle assessment, and if not, I will be having a parent/legal guardian review my forms and sign as well below in conjunction with their permission to allow a nutritionist to provide specific recommendations and/or create a personalized regimen.

This agreement is being signed voluntarily and not under duress of any kind.

By my electronic signature below, I agree to the Newfound Nutrition policy and client agreement stated above.
Date
Print name(s) for Signature
First and last name, [and the name & signature of parent if under the age of 16]
A personal note from Stephen:

"Thanks so much for reaching out and taking the next step toward your personal health goals. I want you to know, that we are all in this together on our journey to better ourselves. I am in no way, shape, or form an authoritative figure. I am just a person who has spent a fair amount of time researching nutritional facts and science as a by-product of curiosity, passion for learning, and drive to feel better. I truly want to just relay the science-based facts and new information I have gathered over the last number of years to like-minded folks and to ones who are in a place that needs a little push in the right direction. I operate as a nutritionist who is on the same level as the client, respecting their wishes and primary concerns only. We are in the same "boat" in terms of trying to become the best version of ourselves and enjoy the time we are given, for us, our family, and our community. Thanks for taking the time to understand this. I look forward to working together to bring each other closer to our health goals."

Yours truly,

Stephen Pelley, RHN - Newfound Nutrition
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Newfound Nutrition - Client Intake Form

~Congratulations on taking the hardest but most necessary step, getting started!~

Initial Health Information & Goals