Holistic Consultation Intake Form

Goals
What is the main reason why you are seeking support?*
Other (please specify)*
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):*

Rows	Yes/No	Quantity	Frequency
Alcohol
Caffeine
Cannabis
Tobacco
Sugar (added, refined, sweets, deserts, sodas/juices)
Artificial Sweeteners
Recreational Drugs
Restaurant/Take-out Food
Prepared Food (meals, snacks or anything else purchased at the grocery or elsewhere)
Water/Carbonated Water
Energy Drinks

YesNoI don't know
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.)?*
YesNoMaybe
Consent and Waiver/Disclaimer
I hereby acknowledge that the purpose of this and future consultations is to help me reconnect with myself, others, animals or nature, and improve my health, well-being, and lifestyle.

I understand that this consultation aims to obtain guidance and information about factors within my control.

I understand that holistic evaluations 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 submitting this form gives them my consent and is a release of their liability.
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Personal Information