Metabolic Intake Form

Metabolic Intake Form
PERSONAL INFORMATION
Which Office Would You Prefer?*
First Name*
Last Name*
Address - Street & Unit*
Address - City, State, Zip*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*
Age*
Occupation*
Include nature of your work (IE Physical, Sedentary)
Biologic Sex*
Based on biology, assigned at birth
Are you married?*

YesNo
Spouse's Name*
Write "N/A" if not applicable.
Do you have children?*

YesNo
Number of Pregnancies *
Children's Names (if applicable)*
MEDICAL HISTORY
Personal Medical History: Check all that apply

DepressionHeart AttackDiabetesThyroid DysfunctionGallbladder IssuesKidney IssuesStrokeFatigueBrain FogHypoglycemiaAnemiaCancerHigh Blood PressureIntestine IssuesShortness of BreathHigh CholesterolHeadachePoor SleepDizzinessArthritisCarpal TunnelNeuropathy / Nerve IssuesWeight GainBack PainNeck PainShoulder PainKnee PainHip PainOther
Would you like the practitioner to present a solution for all checked issues above?*
Family History. Review your Personal Medical History Above. Does anyone in your family suffer from any of those issues? If so, who?*
Type "N/A" if not applicable
Timing. Review your Personal Medical History Above. Is there a certain time of the day that these issues are better or worse? Explain.*
Type "N/A" if not applicable
List your Medications and Supplements.*
If none, type N/A
Pregnancy:*

I am certain that I am NOT pregnantI am certain that I AM pregnantI am UNCERTAIN if I am pregnant
Breastfeeding*

I am NOT breastfeedingI AM breastfeedingI PLAN to breastfeed in the next 6 months
Known Allergies*
List your MAIN CONCERNS 1: * 2: 3: . 4:
How long have you suffered from these concern(s)?*
What effect does this have on your body functions and/or quality of life?*
What would improve if you didn't have these concerns?*

Less stressMore EnergyImproved Family LifeImproved Work LifeImproved Self EsteemImproved OutlookImproved ConfidenceImproved Sleep
How have you addressed weight management in the past?*

MedicationsVitaminsExerciseDiet & NutritionN/AOther
How well did the other methods work for you?*

Not wellSomewhat wellWellN/A
How long did results last?

I didn't get good resultsResults did not last longResults lasted longN/A
What potential barriers do you foresee that would prevent the change you are looking for?*
Do you feel that it is possible to eliminate or prevent these potential barriers?*
What outcome would you like to see in order for this to be a success for you?*
PLEASE RATE THE FOLLOWING ON A SCALE OF 1 - 10

(1 = Lowest. 10 = Highest)
Energy Level*

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1 is Worst, 10 is Best
Sleep Quality*

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1 is Worst, 10 is Best
Importance for you to resolve your health concerns*

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10

1 is Worst, 10 is Best
Level of preparedness to make necessary lifestyle changes to achieve your goals*

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10

1 is Worst, 10 is Best
I am interested in:*

Weight LossLoss of InchesAnti-AgingMetabolism SupportLong-Term Results
Should be Empty:

Metabolic Intake Form

PERSONAL INFORMATION

MEDICAL HISTORY

PLEASE RATE THE FOLLOWING ON A SCALE OF 1 - 10