Intake Data

Do you wake often?

YesNo

If so, why and at what times?

Do you feel rested when you wake up for the day?

Do you have pain when you first get up?

YesNo

If so, where?

Does it go away upon moving?

YesNo

Do you have daily bowel eliminations?

YesNo

If yes, how many per day?

Color

Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided. (refer to the link below for Bristol Stool chart) ittps://media.npr.org/assets/img/2012/11/19/bristol_stool chart custom- 2a0538e55c3f21eff2be62e45dcf24b784426e46-s6-c10.jp

BSC#

Are you post-menopausal? If yes, at what age did you enter menopause?

What are the characteristics of your menopausal experience?

Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?

YesNo

Are you now, or in the near future, planning to become pregnant?

YesNo

Is your menstrual cycle regular?

YesNo

Longer or shorter than 28 days?

Is your flow longer or shorter than 5 days?

Do you have cramps or clotting?

YesNo

Would you describe the color of your menses as bright red, dark purple, or brown?

Do you experience PMS, cyclical headaches or cravings?

YesNo

Have you experienced issues with adrenal or thyroid functions?

YesNo

Prostate problems

YesNo

Do you take any supplements? If so, what, how often and why?

Do you take any OTC medications routinely (such pain reliever or allergy medicine)? If so, what and how often

Have you had any surgeries? If so, what and when?

Have you received any diagnoses from licensed medical professionals? If so, what and when

Have you ever been in consultation with a naturopath? If so, why? How long ago?

What was suggested?

Did you experience a good outcome?

What did you like about it?

What wasn't as successful for you?

Do you have regular adjustments with a chiropractor?

Do you have regular body work/massages?

Please check all with which you are familiar:

What are your expectations from our meetings?

How committed are you to change?

Is there anything else that you believe is important for me to know about you?

I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease.

Signature*

Date

MonthDayYear

Intake Data

Reason for visit (prioritized)

Nutritional data

How much of the following do you consume?

Timing

Movement

Sleep

Eliminations

Females

Male

Medical History

Naturopathic history:

Consultation Finding