Client Intake Form

Attn: parents/guardians please fill out client intake form for each client/child.
Client's Name*

First NameLast Name
Guardian Name (if applicable)

First NameLast Name
Client/Guardian Email*
example@example.com
Client's Gender
Client's Birth Date*

MonthDayYear
1. List Diagnosis including year.
Brain fogLethargyMental fatigueAnxietyLow moodConfusionIrritabilityAngerSleeping issuesRacing thoughtsAggression/angerPanicTenseLack of focusConcentrationHeadachesEmotional dysregulationNutritional deficienciesOther
3. List any surgeries involving anesthesia.
a) transition from medication to micronutrientsb) stay on medicationc) I don’t knowd) not taking medication but looking to improve overall health
5. List your current medications ex; Psychiatric, Thyroid, Blood pressure, Sleep medication, Hormone, Insulin, histamine)
6. Are you currently taking any Hardy Supplement Products?
MultivitaminOmega 3ProbioticSt John's wortKava kavaSkullcapGABA5HTPSAMeAshwagandhaValerianMelatoninOther
Example; vitamin D 1000iu, magnesium 200mg etc.
8. List your past medications ex; Psychiatric, Thyroid, Blood pressure, Sleep medication, Hormone, Insulin, histamine)
YesNo
YesNo
If yes, how many times have you used antibiotics in the last 5 years?
No digestive issuesDiarrheaConstipationAlternating diarrhea/constipation1 Bowel movement daily2 Bowel movements DailyBloatingBurpingGasHeartburnCravings for sugar/carbs/salty foodsFood sensitivitiesHistory of parasitesYeast infections
AlcoholMarijuanaPsychedelicsNicotineCaffeine
How many cups/oz per day?

13. What is your typical diet like?

Rows
Breakfast
Lunch
Dinner

Disclosure of Health Information

Without a patient’s permission, Hardy Nutritional’s cannot disclose any personal health information to anyone outside of the patient’s circle of care. Personal Information Protection Act (PIPA), clients give their verbal consent to disclose their information for the purpose of communicating with our staff regarding the patient’s medical information.
Signature*
Date*

MonthDayYear
Date
Should be Empty: