Intake Form

Name

Address

Age

Telephone(Best):

Email

example@example.com

Reason for visit (prioritized):

1

2

3

How many ounces of water/day and what kind?

What other beverages and how much?

Do you use artificial sweeteners?

If so which ones?

How often and in what?

Do you eat Breakfast? If so. what?

How much of the following do you consume? (example: 1D = 1/day, 2W = 2/week, 3M = 3/month)

Fresh fruit

Raw vegetables

Fermented foods

Fast foods

Meat

Eggs

Dairy

What do you crave?

What foods do you dislike the most?

Timing:

What is the first thing you do when you get up in the morning?

What time do you eat your first meal?

time of Last meal?

Which meal is your largest of the day?

Describe a typical largest meal.

Do you exercise/move/participate in fun sweaty activity If so what and how often?

Do you look forward to it?

How do you feel when you are finished?

Sleep:

What time do you go to bed?

How long do you sleep?

Do you wake often?

If so why and at what times?

Do you feel rested when you wake up for the day?

Do you have pain when you first get up? Does it go away upon moving?

Elimination:

Do you have daily bowel eliminations? How many per day?

Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided. BSC #Color

Female:

Are you post-menopausal? If yes, at what age did you enter menopause?

Do you currently use Hormone Replacement HRT or Hormonallybased Contraception?

Are you now or in the near future planning to become pregnant?

Is your menstrual cycle regular?

Longer than 28 days?

Shorter?

Is your flow longer or shorter than 5 days?

DO you have cramps or clotting?

Would you describe the color of your menses as bright red, dark purple, or brown?

Do you experience PMS cyclical headaches or cravings?

Supplements/medications:

Do you take any supplements?If so, what, how often and why?

List your supplements:

Do you take any OTC medications routinely such pain reliver or allergy medicine If so what and how often

Do you take prescription medications (prescribed by a licensed medical professional?) If so, what and how often?

Medical history:

Have you had any surgeries? if so, what and when?

Have you received any diagnoses from licenses medical professionals? if so, what and when?

Naturopathic history:

Have you ever been in consultation with a naturopath? If so, why? How long ago?

What was suggested?

Did you experience a good outcome?

What did you like about it?

What wasn't as successful for you?

Do you have regular adjustments with a chiropractor?

Do you have regular body work/massages?

Please check all which you are familiar:

| understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease.

Signature

Date

Office use Only:

Total Carbs

pH

Total Salts

Cell Debris

Ureas

Total Ureas

Face Findings

Tongue Findings

Nail Findings

Active MRT Points

Recommendations

Next consultation recommended on