Dr. Kar's Clinic Intake Form Aug 2024

Full Name*
Today's Date*

MonthDayYear
Date of Birth*

MonthDayYear
Age*
Gender*

FemaleMalePrefer not to say
City*
Country*
I came to know of your program from*

Referred by friendInternet SearchReferred by my healthcare providerOther
Height (In inches or centimeters)
Waist Circumference (In inches or centimeters)
Height / Waist circumference. Waist circumference more than half of height is a rough measure of metabolic dysfunction.
Current Weight
Desired Weight
Body Fat Percentage (If known)
Birth Weight (If known)
I was born by

Normal Vaginal DeliveryCaesarean SectionForceps/ Vacuum ExtractionDon't know
Family/Living Situation:

Living with spouse/partnerLiving aloneLiving with extended family (parents,siblings etc)
Children

None1234More than 4
Do your children have any health challenge ?

YesNo
If yes, please describe
Present Occupation
Previous Occupation (if any)
HISTORY
Have you or your family recently experienced any major life changes? If so, please comment:
How much time have you had to take off from work or school in the last year?

0 to 2 days3 to 14 daysMore than 15 days
HEALTH CONCERNS
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealt with these concerns in the past?

DoctorsSelf-care
Have you experienced any success with these approaches? If so, please explain:
What other types of health practitioners or healers are you currently seeing?
Have you undergone any surgical procedures? Please list with approximate dates.
How often have you taken antibiotics in both your childhood and adult life

Less than 5 timesMore than 5 times
Please list any prescription medications you are currently taking
Please list all vitamins, minerals, herbs and nutritional supplements you are now taking:
NUTRITIONAL STATUS
Eating Window
My first food or drink intake of the day is at*

:HourMinutesAM/PM Option
My last food or drink intake of the day is at*

:HourMinutesAM/PM Option
Your relationship with food

Do you have a healthy relationship with food?
Have you been diagnosed with any of the conditions listed here? If yes, select the ones that apply.*

NoDon't knowFood addictionAnorexia nervosaBinge eating disorderBulimia nervosaAvoidant or restrictive food intake disorderPicaRumination disorder
Do you often eat when you are tired, bored, stressed or sad?*

YesNo
Do you find yourself eating large amounts of food in a short period of time, even when you feel uncomfortably full??*

YesNo
Do you feel guilty, ashamed, or distressed about your eating habits or food choices?*

YesNo
Do you use food as a reward or comfort, and do you feel a loss of control over your eating at these times?*

YesNo
Food Sensitivities
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom: (For example, wheat-bloating)
Do you experience symptoms immediately after eating like bloating, gas, sneezing or hives? If you do, please explain:
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, If you do, please explain:
Do you crave specific foods or drinks? If you do, please explain:
Are you aware of any food allergies or sensitivities? If you are, please explain
Please list the foods you eat regularly for meals and snacks
Which of the following foods do you consume regularly?

Soda/Cold DrinksRefined sugarFast foodDiet soda/Diet cold drinksDairy (milk, cheese, yogurt)AlcoholGluten (wheat, rye, barley)CoffeeTea
Meals and Snacks
Breakfast
Lunch
Dinner
Snacks
Alcohol Intake

Based on Canada’s Guidance on Alcohol and Health 2023
What is your risk?*

No riskLow riskModerate riskIncreasingly high risk
Do you now or have you in the past used or abused alcohol, drugs, prescription and non-prescription medications, tobacco or caffeine? Please explain:
GUT STATUS
Bowel Movement Frequency

1 to 3 times per dayMore than 3 times per dayNot regularly every day
Bowel Movement Consistency*

Type 1Type 2Type 3Type 4Type 5Type 6Type 7
Do you experience intestinal gas? If so, please explain: Is it excessive, occasional, odorous etc.?
MEDICAL STATUS
Please check any of the following conditions that may apply to you and your history.

AllergiesAnaemiaAsthmaCancerHigh CholesterolDepressionDiabetesHigh Blood Pressure (Hypertension)Heart DiseaseHepatitisHead trauma with or without concussionKidney DiseaseThyroid DiseaseSexually Transmitted DiseaseStrokeChronic yeast infectionAny autoimmune diseaseOther
Briefly describe your symptoms, chosen treatment(s), and dates of any of the conditions mentioned above
Adverse Life Experiences
Have you experienced any form of abuse (physical, emotional, or sexual) in your life?*

YesNo
Medical Symptoms Questionnaire

In the sections below please score based on the point scale
Point Scale

0 - Never or almost never have the symptom
1 - Occasionally have it; the effect is not severe
2 - Occasionally have it; the effect is severe
3 - Frequently have it; the effect is not severe
4 - Frequently have it, the effect is severe
HEAD