Intake Data

  • Intake Data

  • Date
     / /
  • Format: (000) 000-0000.

  • Reason for visit (prioritized)

  • Nutritional data

  • Do you use artificial sweeteners?
  • Do you eat breakfast?

  • How much of the following do you consume?

    (example: 1D = 1/day, 2W = 2/week, 3M = 3/month) 

  • Timing

  • Movement

  • Sleep

  • Do you wake often?
  • Do you have pain when you first get up?
  • Does it go away upon moving?

  • Eliminations

  • Do you have daily bowel eliminations?

  • 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

  • Females

  • Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?
  • Are you now, or in the near future, planning to become pregnant?
  • Is your menstrual cycle regular?
  • Do you have cramps or clotting?
  • Do you experience PMS, cyclical headaches or cravings?
  • Have you experienced issues with adrenal or thyroid functions?

  • Male

  • Prostate problems

  • Medical History

  • Naturopathic history:

  • Please check all with which you are familiar:

  • 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.

  • Date
     / /

  • Consultation Finding

  • Should be Empty: