New Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
What are your health goals in order of importance?
*
Are you willing to do what it takes to achieve these goals?
Current height and weight:
List any supplements you are currently taking and dosages/strengths.
List any medications you are currently taking and dosages/strengths.
What is your blood type (if known)?
Have you had any surgeries/organs removed?
What type of exercise or physical work do you do?
What is your occupation?
How many hours of sleep do you normally get? Do you wake up feeling rested?
What time do you normally go to bed?
Do you nap? If so, what time and for how long?
Do you have any of the following?
Bowel movements/stool:
Without going into too much detail, what types of stress are you currently under? (ex: financial, marital/relational, work, family, physical, other)
What do you normally eat for breakfast? And typically at what time?
What do you normally eat for lunch? And typically at what time?
What do you normally eat for dinner? And typically at what time?
List any snacks and typically at what time you eat them.
List beverages consumed (including alcohol) and approximate ounces (per day, on average).
How often do you have bowel movement? Using the Bristol Stool chart (found online) describe them and how often.
Do you ever have any abdominal pain? If so, please describe type of pain (sharp, crampy, burning, etc), location (example: sharp, left upper side) and when/how often (example: occasionally after eating a meal).
Do you ever use antibiotics? If so, for what and how often?
Rate your stress level at this point in your life. 1-10, with 10 being the most stressed.
Submit
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