Flourish Nutrition Physical

Client Intake Form
Name

First NameLast Name
Parent or Guardian (If a Minor)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Date Of Birth

MonthDayYear
Date
Height
Weight
Race
Marital Status

MarriedSingle
Occupation
Blood Type

A+A-B+B-AB+AB-O+O-
Medical History (Check all that apply)

ArthritisChronic InfectionsAsthmaBronchitisAllergies/Hay FeverEmphysemaCancerChronic Tiredness/FatigueThyroid DysfunctionDigestion ProblemsAnginaHeart AttackHeart DiseasePacemakerDifibrillatorHigh CholesterolHigh HomocysteineHigh Blood PressureDiabetesHypoglycemiaOsteoporsisHormone ImbalancesVaginal DrynessProstate - EnlargedDepressionHeadaches/MigranesEye ProblemsDry EyesKidney/Bladder DisordersLiver Disease
Today's Health Concern(s)
Primary Care Physician

First NameLast Name
Primary Care Physician Phone Number
Please enter a valid phone number.
Dentist

First NameLast Name
Dentist Phone Number
Please enter a valid phone number.
Chiropractor

First NameLast Name
Chiropractor Phone Number
Please enter a valid phone number.
Pharmacy
Pharmacy Phone Number
Please enter a valid phone number.
May we contact you health care provider(s) for additional information or to inform them of health concerns we may have?

YesNo
Other health concerns not previously listed.
Current prescription medications.
Current non-prescription medications, vitamins, minerals, herbal supplements and self-care.
Medical Symptoms Questionnaire

Rate each of the following symptoms based on your typical health profile for the past month.
Head - Headaches

0

1

2

3

4

0 is Never, 4 is Frequently
Head - Faintness

0

1

2

3

4

0 is Never, 4 is Frequently
Head - Dizziness

0

1

2

3

4

0 is Never, 4 is Frequently
Head - Insomnia

0

1

2

3

4

0 is Never, 4 is Frequently
Head Total
Eyes - Watery/Itchy Eyes

0

1

2

3

4

0 is Never, 4 is Frequently
Eyes - Swollen, reddened or sticky eyelids

0

1

2

3

4

0 is Never, 4 is Frequently
Eyes - Bags or dark circles under eyes

0

1

2

3

4

0 is Never, 4 is Frequently
Eyes - Blurred or tunnel vision

0

1

2

3

4

0 is Never, 4 is Frequently
Eyes Total
Ears - Itchy Ears

0

1

2

3

4

0 is Never, 4 is Frequently
Ears - Earaches, Ear Infections

0

1

2

3

4

0 is Never, 4 is Frequently
Ears - Drainage from ear

0

1

2

3

4

0 is Never, 4 is Frequently
Ears - Ringing or hearing loss

0

1

2

3

4

0 is Never, 4 is Frequently
Ears Total
Nose - Stuffy Nose

0

1

2

3

4

0 is Never, 4 is Frequently
Nose - Sinus Problems

0

1

2

3

4

0 is Never, 4 is Frequently
Nose - Hay Fever

0

1

2

3

4

0 is Never, 4 is Frequently
Nose - Sneezing Attacks

0

1

2

3

4

0 is Never, 4 is Frequently
Nose - Excessive Mucus

0

1

2

3

4

0 is Never, 4 is Frequently
Nose Total
Mouth/Throat - Chronic Coughing

0

1

2

3

4

0 is Never, 4 is Frequently
Mouth/Throat - Gagging or frequent need to clear throat

0

1

2

3

4

0 is Never, 4 is Frequently
Mouth/Throat - Sore throat, hoarseness or loss of voice

0

1

2

3

4

0 is Never, 4 is Frequently
Mouth/Throat - Swollen or discolored tongue, gums or lips

0

1

2

3

4

0 is Never, 4 is Frequently
Mouth/Throat - Canker Sores

0

1

2

3

4

0 is Never, 4 is Frequently
Mouth/Throat Total
Skin - Acne

0

1

2

3

4

0 is Never, 4 is Frequently
Skin - Hives, rashes, or dry skin

0

1

2

3

4

0 is Never, 4 is Frequently
Skin - Hair Loss

0

1

2

3

4

0 is Never, 4 is Frequently
Skin - Flushing, hot flashes

0

1

2

3

4

0 is Never, 4 is Frequently
Skin - Excessive sweating

0

1

2

3

4

0 is Never, 4 is Frequently
Skin Total
Heart - Chest Pain

0

1

2

3

4

0 is Never, 4 is Frequently
Heart - Irregular or skipped heartbeat

0

1

2

3

4

0 is Never, 4 is Frequently
Heart - Rapid or pounding heartbeat

0

1

2

3

4

0 is Never, 4 is Frequently
Heart Total
Lungs - Chest congestion

0

1

2

3

4

0 is Never, 4 is Frequently
Lungs - Asthma, bronchitis

0

1

2

3

4

0 is Never, 4 is Frequently
Lungs - Shortness of breath

0

1

2

3

4

0 is Never, 4 is Frequently
Lungs - Difficulty breathing

0

1

2

3

4

0 is Never, 4 is Frequently
Lungs Total
Digestive Tract - Nausea, vomiting

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract - Diarrhea

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract - Constipation

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract - Bloated Feeling

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract - Belching, passing gas

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract - Heartburn

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract - Intestinal/Stomach Pain

0

1

2

3

4

0 is Never, 4 is Frequently
Digestive Tract Total
Joints/Muscle - Pain or aches in joints

0

1

2

3

4

0 is Never, 4 is Frequently
Joints/Muscle - Arthritis

0

1

2

3

4

0 is Never, 4 is Frequently
Joints/Muscle - Stiffness or limitation of movement

0

1

2

3

4

0 is Never, 4 is Frequently
Joints/Muscle - Feeling of weakness or tiredness

0

1

2

3

4

0 is Never, 4 is Frequently
Joints/Muscle - Pain or aches in muscles

0

1

2

3

4

0 is Never, 4 is Frequently
Joints/Muscles Total
Weight - Binge eating/drinking

0

1

2

3

4

0 is Never, 4 is Frequently
Weight - Craving certain foods

0

1

2

3

4

0 is Never, 4 is Frequently
Weight - Excessive weight

0

1

2

3

4

0 is Never, 4 is Frequently
Weight - Water retention

0

1

2

3

4

0 is Never, 4 is Frequently
Weight - Underweight

0

1

2

3

4

0 is Never, 4 is Frequently
Weight - Compulsive eating

0

1

2

3

4

0 is Never, 4 is Frequently
Weight Total
Energy/Activity - Fatigue, sluggishness

0

1

2

3

4

0 is Never, 4 is Frequently
Energy/Activity - Apathy, lethargy

0

1

2

3

4

0 is Never, 4 is Frequently
Energy/Activity - Hyperactivity

0

1

2

3

4

0 is Never, 4 is Frequently
Energy/Activity - Restlessness

0

1

2

3

4

0 is Never, 4 is Frequently
Energy/Activity Total
Mind - Poor memory

0

1

2

3

4

0 is Never, 4 is Frequently
Mind - Confusion, poor comprehension

0

1

2

3

4

0 is Never, 4 is Frequently
Mind - Difficulty in making decisions

0

1

2

3

4

0 is Never, 4 is Frequently
Mind - Stuttering or stammering

0

1

2

3

4

0 is Never, 4 is Frequently
Mind -Slurred speech

0

1

2

3

4

0 is Never, 4 is Frequently
Mind -Learning disabilities

0

1

2

3

4

0 is Never, 4 is Frequently
Mind -Poor concentration

0

1

2

3

4

0 is Never, 4 is Frequently
Mind -Poor physical coordination

0

1

2

3

4

0 is Never, 4 is Frequently
Mind Total
Emotions - Mood swings

0

1

2

3

4

0 is Never, 4 is Frequently
Emotions - Anxiety, fear, nervousness

0

1

2

3

4

0 is Never, 4 is Frequently
Emotions - Anger, irritability, aggressiveness

0

1

2

3

4

0 is Never, 4 is Frequently
Emotions - Depression

0

1

2

3

4

0 is Never, 4 is Frequently
Emotions Total
Other - Frequent Illness

0

1

2

3

4

0 is Never, 4 is Frequently
Other - Frequent or urgent urination

0

1

2

3

4

0 is Never, 4 is Frequently
Other - Genital itch or discharge

0

1

2

3

4

0 is Never, 4 is Frequently
Other Total
Medical Symptoms Questionnaire Grand Total
Xenobiotic Tolerability Test (XTT)
Are you presently using prescription drugs?

YesNo
If yes, how many are you currently taking?

Are you presently taking one or more of the following over-the-counter drugs?

	Yes	No
Cimetidine
Acetaminophen
Estradiol

If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them?

	Yes	No
Experience side effects, drug(s) is (are) efficacious at lowered dose(s)
Experience side effects, drug(s) is (are) efficacious at usual dose(s)
Experience no side effects, drug (s) is (are) usually not efficacious
Experience no side effects, drug(s) is (are) usually efficacious

Do you currently use or within the last 6 months had your regularly used tobacco products?

YesNo
Do you have strong negative reactions to caffeine or caffeine-containing products?

YesNoDon't Know
Do you commonly experience "brain fog", fatigue, or drowsiness?

YesNo
Do you develop symptoms on exposure to fragrances, exhaust, fumes, or strong odors?

YesNoDon't Know
Do you feel ill after you consume even small amounts of alcohol?

YesNoDon't Know

Do you have a personal history of (Check all that apply)


Environmental and/or chemical senitivities
Chronic fatigue syndrome
Multiple chemical sensitivity
Fibromyalgia
Parkinson's type symptoms
Alcohol or chemical dependence
Asthma

Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?

YesNo
Do you have adverse or allergic reactions when you consume sulfite-containing foods such as wine, dried fruit, salad bar vegetables, etc?

YesNoDon't Know
Alkalizing Assessment
Do you have a history or currently have kidney dysfunction?

YesNo
Have you ever been diagnosed with a condition known as hyperkalemia?

YesNo
Are you currently on diuretics or blood pressure medication?

YesNo
Stomach & Esophagus

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Indigestion, food repeats on you after you eat
Excessive burping, belching and/or bloating following meals
Stomach spasms and cramping during or after eating
A sensation that food just sits in your stomach, creating uncomfortable fullness, pressure, and bloating during or after a meal
Bad taste in your mouth
Small amounts of food fill you up immediately
Skip meals or eat erratically because you have no appetite

Stomach

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Strong emotions, or the thought or smell of food aggravates you stomach or makes it hurt
Feel hungry an hour or two after eating a good-sized meal
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
Burning sensation in the lower part of our chest, especially when lying down or bending forward
Digestive problems that subside with rest and relaxation
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus, or hot peppers causes your stomach to burn or ache.
Feel sense of nausea when you eat
Difficulty or pain when swallowing food or beverage

Small Intestine, Pancreas, Gallbladder

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
When massaging under your rib cage, on your left side, there is pain, tenderness or soreness.
Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
Specific foods/beverages aggravate indigestion
The consistency or form of your stool changes (e.g, from narrow to loose) within the course of a day
Stool odor is embarrassing
Undigested food in your stool
Three or more large bowel movements daily
Diarrhea (frequent loose, watery stool)
Bowel movement shortly after eating (within 1 hour)

Colon

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Discomfort, pain or cramps in your colon (lower abdominal area)
Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
Generally constipated (or straining during bowel movements)
Stool is small, hard and dry
Pass mucus in your stool
Alternate between constipation and diarrhea
Rectal pain, itching or cramping
No urge to have a bowel movement
An almost continual need to have a bowel movement

Liver & Gallbladder

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
When massaging under your rib cage on your right side, there is pain, tenderness or soreness
Abdominal pain worsens with deep breathing
Pain at night that may move to your back or right shoulder
Bitter fluid repeats after eating
Feel abdominal discomfort or nausea when eating rich, fatty or fried foods
Throbbing temples and/or dull pain in forehead associated with overeating
Unexplained itchy skin that's worse at night
Stool color alternates from clay colored to normal brown
General feeling of poor health
Aching muscles not due to exercise
Retain fluid and feel swollen around the abdominal area
Reddened skin, especially palms
Very strong body odor
Are you embarrassed by your breath?
Bruise easily
Yellowish cast to your eyes

Thyroid

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Feel cold or chilled-hands, feet or all over-for no apparent reason
Your upper eyelids look swollen
Muscles are weak, cramp and/or tremble
Are you forgetful?
Do yo feel like your heart beats slowly?
Reaction time seems slowed down
In general, are you disinterested in sex because your desire is low?
Feel slow-moving, sluggish
Constipation
Dryness, discoloration of skin and/or hair
Have you noticed recently that your voice is deepening?
Thick, brittle nails
Weight gain for no apparent reason
Outer third of your eyebrow is thinning or disappearing
Swelling of the neck

Adrenal

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Lingering mild fatigue after exertion or stress
Do you find that you get tired and exhaust easily?
Craving for salty foods
Sensitive to minor changes in weather and surroundings
Dizzy when rising or standing up from a kneeling position
Dark bluish or black circles under your eyes
Have bouts of nausea with or without vomiting
Catch colds or infections easily
Wounds heal slowly
Your body or parts of your body feel tender, sore, sensitive to the touch, hot and/or painful
Feel puffy and swollen all over your body
Skin is gradually tanning without exposure to the sun or the ingestion of high levels of carotene-rich foods (e.g. daily carrot juice intake) or supplements

Lower Glucose

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
A sense of weakness
A sudden sense of anxiety when you get hungry
Tingling sensation in your hands
A sensation of your heart beating too quickly for forcefully
Shaky, jittery, hands trembling
Sudden profuse sweating and/or your skin feels clammy
Nightmares possibly associated with going to bed on an empty stomach
Wake up at night feeling restless
Agitation, easily upset, nervous
Poor memory, forgetful
Confused or disoriented
Dizzy, faint
Cold or numb
Mild headaches or head pounding
Blurred vision or double vision
Feel clumsy and uncoordinated

Higher Glucose

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Frequent urination during the day and night
Unusual thirst-feeling like you can't drink enough water
Unusual hunger-eating all the time
Vision blurs
Feel itchy all over
Tingling or numbness in your feet
Sense of drowsiness, lethargy during the day not associated with missing meals or not sleeping
Eating starchy foods, even if they are healthy and unprocessed (like rice, corn, beans, whole wheat, or oats), causes you to gain weight or prevents you from losing weight
Sores heal slowly
Loss of hair on your legs

Heart

Check all that apply

	No/Rarely	Occasionally	Often	Frequently
Feel jittery
First effort of the day causes pain, pressure, tightness or heaviness around the chest
Heavy sweating (no exertion, no hot flashes)
Difficulty catching breath, especially during exercise
Heart pounding, sensation of heart beating too quickly, too slowly or irregularly
Swelling in feet, ankles and/or legs comes and goes for no apparent reason

Elimination Assessment
How many bowel movements do you typically have per day?
How many bowel movements do you typically have in a week?
How many times do you typically use a laxative in a day?
How many times do you typically use a laxative in a week?

My stools are

	1 Never	2 Infrequent	3 Frequently	4 Constantly
Large (3 fingers wide and 6: plus in length)
Soft and well-formed (smooth texture)
Medium (2 fingers wide and 4-6" plus in length and well-formed)
Thin, long and narrow stools
Often float
Small and hard
Large and hard
Difficult to pass
Loose, but not watery
Diarrhea
Alternates between hard (constipated) and loose and watery (diarrhea-like)

My stool odor is:

	1 Never	2 Infrequent	3 Frequently	4 Constantly
Offensive usually
Offensive occasionally
Little odor usually

My stool color is:

	1 Never	2 Infrequent	3 Frequently	4 Constantly
Medium brown (peanut butter color), consistently
Dark brown, consistently
Very dark
Black
Yellow
Light brown
Clay or putty colored
Greenish color
Greasy, shiny appearance
Blood is visible in them
Have mucus in them
Varies a lot

My intestinal gas is:

	1 Never	2 Infrequent	3 Frequently	4 Constantly
Daily
Occassionally
Excessive
Present with pain
Foul smelling
Little odor

Do you have trouble initiating your bowel movement?

YesNo
Does abdominal discomfort or cramping ever accompany bowel movements? Yes 1 No . If so, how often? Input frequency
Have you ever been diagnosed as having dental, gum, mouth, stomach, liver, gallbladder, pancreas, intestinal, or bowel disorder or disease? Yes No.
If yes, please explain.
Have you had or do you have hemorrhoids or varicose veins? Yes No
If yes, please explain
Do you make a conscious effort to eat a high fiber diet? Yes No
What do you eat?
Do you usually pay attention when nature calls? Yes No
Meal Record

Provide a week of meals.
Name: Full Name | Week of: Week date range

Meal Record

	Breakfast	Snack	Lunch	Snack	Supper	Snack	Fluids
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Nutritional Consultation Disclaimer: By checking below, you understand that any products, supplements, or recommendations discussed or provided during this assessment and consultation have not been evaluated or approved by the U.S. Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any disease. The information shared is based on general nutritional principles and professional experience. Participation in this consultation does not create a healthcare provider-patient relationship. The consultant is not a licensed medical professional and cannot provide medical diagnoses or treatments. Individual results may vary based on personal factors, and any actions you take based on the information provided are at your own risk. This consultation is for educational purposes. It is important to consult with your healthcare professional before making any changes to your diet, exercise, or supplement regimen. By participating in this nutritional consultation, you acknowledge and agree to these terms and understand the limitations of the information provided. Always consult a healthcare professional before making any significant changes to your lifestyle, diet, supplement, or health practices.*

I have read and agree with the above disclaimer.
Signature*

Clear
Should be Empty:

Client Intake Form

Medical Symptoms Questionnaire

Xenobiotic Tolerability Test (XTT)

Alkalizing Assessment

Stomach & Esophagus

Stomach

Small Intestine, Pancreas, Gallbladder

Colon

Liver & Gallbladder

Thyroid

Adrenal

Lower Glucose

Higher Glucose

Heart

Elimination Assessment

Meal Record