Holistic Consultation Intake Form

Goals
What is the main reason why you are seeking support?*
What do you hope to get out of this Holistic Consultation?*
Health Status
Do you have any current health conditions?*
Please indicate when they started, if something happened in your life around the same time and how you manage them.
Did you have any past health conditions that have resolved?*
Please indicate when they started and how long they lasted, if something happened in your life around the same time and how you did manage them.
Do you have a specific diet or dietary restrictions (preferences, allergies, intolerances, eating disorder)? If yes, please list them down below, provide a description and indicate if you take any medication for each of them.*
Are you currently taking any other medication? If yes, please list them below.*
This includes vitamins, supplements, and other medications you're taking.

Indicate if you consume the following (if yes, quantity and frequency):*

	Yes/No	Quantity	Frequency
Alcohol
Caffeine
Cannabis
Tobacco
Sugar (added, sweets, deserts, sodas/juices)
Artificial Sweeteners
Recreational Drugs
Restaurant/Take-out Food
Prepared Food (grocery meals, snacks, etc.)
Water/Carbonated Water
Energy Drinks

Are you pregnant? (women)*

YesNo
Do you exercise? If yes, please describe what you do, where you do it, how often you do it and when you started.*
Do you play sports? If yes, please indicate which ones, how often you practice them and when you started to play them.*
What other activities do you enjoy in your free time?*
Ex: Dance, hiking, yoga, etc.
What is your stress level on a scale of 1-10 (10 being the highest) and how do you deal with it?*
How many hours do you normally sleep and what is the quality?*
How would you describe a typical day in your life or daily routine (foods, drinks, sleep, exercise, movement, activities, work)?*
What is your relationship with food (how you feel about it, cooking habits, etc.)?*
How would you describe yourself?*

Are there any barriers that may influence your food or other choices (budget, living arrangements, schedule, etc.)?*
Are you willing to change your habits?

YesNo
Consent and Waiver/Disclaimer
I hereby acknowledge that the purpose of this and future consultations is to help improve my health, well-being, and lifestyle.

I am seeking the services of the consultant to help support my health and wellness and obtain guidance and information about factors within my control such as food choices and diet, stress reduction and lifestyle, hydration and other related factors.

I understand that holistic evaluations and lifestyle assessments are not intended for the diagnosis of disease and that the consultant is a holistic educator and does not dispense medical advice, provide diagnoses or prescribe treatment.

I understand that signing this consent form is a release of their liability.
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