New Patient Intake forms

Welcome! Here's the first step to an incredible new journey!

This form serves as a way for me to get to know you better so I can choose the appropriate supplements. It is completely HIPAA compliant, your information is confidential and nothing will be shared with anyone else.
Name*

First NameLast Name
Email*
example@example.com
How did you hear about the program?*
*Supplements are shipped USPS Priority. Where would like your products shipped to you?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Date of Birth*

YearMonthDay
Date
Gender
Have you ever done an elimination diet, detox or cleanse? How did it go?*
What are the reasons you are interested in doing an elimination and detox program now?*
Describe your consumption of caffeine, alcohol and any other recreational drugs, include frequency and amounts. Please be specific. *
Would you say you have a "sensitive stomach", do you have any known intolerances, sensitivities or allergies to foods? Are you sensitive to grains overall?*
Describe your bowel movements; How many times per day? What is the shape? Are they painful or difficult?*
Describe your sleep; how many hours, do you wake up in the middle of the night and can't go back to sleep, do you wake up to urinate, do you have vivid or stressful dreams? *
Do you suffer from fatigue?*
Would you say you experience gastrointestinal bloating often?*
Would you say you suffer from low blood sugar? Ex. lightheaded or shaky if you haven't eaten in a few hours. *
Do you ever suffer from food coma? *
What do you crave and when? Ex. Sweet, salty, spicy, acidic like vinegar*
Are you vegetarian or vegan?*

Personal Medical History (check any that apply):

	Past condition	Ongoing condition
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease

	Past condition	Ongoing condition
Heart Attack
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)

	Past condition	Ongoing condition
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility

	Past conditon	Ongoing condition
Kidney stones
Gout
Gall Bladder stones
Osteoarthritis
Fibromyalgia
Chronic Pain
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid Arthritis

	Past condition	Ongoing condition
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea

	Past condition	Ongoing condition
Depression
Anxiety
Headaches
Migraines
ADD/ADHD
Autism
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis

Gynecological Assessement

Fibrocystic breastsEndometriosisFibroidsPainful periodsHeavy PeriodsHot FlashesNight SweatsMood Swings
Please list ALL Medications you are currently taking:*
Please list ALL Supplements/Herbs you are currently taking:*
Should be Empty: