Wellness Intake form

Your main health problems:

Stress and Lifestyle
Rate your overall stress level on a scale of 1 to 10 (10 = high; 1 = low)
What is affecting your stress level the most?
What do you enjoy most in your life?
What do you worry about most in your life?
When it comes to FULLY committing to your desire to be healthy, what is getting in the way?
Who will sincerely support you consistently with the beneficial lifestyle changes you will be making?
List any emotional or personal conflicts that you are exposed to repeatedly:
What are your hobbies?
How much sleep do you get on average per night?

1 -3 hours4 - 5 hours6 -7 hours7 + hours

	Give examples of what foods you typically eat daily:
Breakfast
Lunch
Snacks
Dinner
Liquids

List any major illnesses/diagnosed conditions with approximate dates:

Commitment to Your Health
How serious are you about improving your health?

Very seriousSeriousModerately InterestedOther
I Will Commit to Do the Following, if necessary:

Change my dietUse supplementsDo detoxification recommendations using sauna/other therapiesWhatever it takesDepends on the scan results
Should be Empty:

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Heartburn or Acid Reflux
Burping or Gas after eating
Bloating after eating
Bad breath
Sweat has a strong odor
Feel better if I don’t eat
Sleepy after meals
Burning pain in stomach
Fingernails chip, break, peel
Anemia unresponsive to iron
Stomach pain or cramps
Diarrhea, chronic
Diarrhea after meals
Black or dark stool
Undigested food in stool

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Skip days between bowel movments
Stools hard or difficult to pass
Cramping on lower abdomen
Blood in stool
Mucus in stool
IBS or colitis
Yeast Infections
Nail fungus or athletes foot
Dark circles under eyes
History of parasites
Coated tongue
Anus itches
Constipation
Stools are loose
Bad smelling gas

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Bad smelling gas
Food allergies
Bloating after eating
Airborne allergies
Wheat or gluten sensitivity
Dairy sensitivity
Sinus congestion
Craves bread and pasta
Pulse speeds after eating
Nightmares
Feel spacy or unreal
Alternating diarrhea/ constipation
Hives

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Hives
Nausea
Pain between shoulder blades
Skin rashes, acne, eczema, etc.
Age or “Liver” spots
Greasy foods upset stomach
Gallbladder attacks or stones
Motion sickness
Headache over eyes
Easily intoxicated
Hemorrhoids or varicose veins
Sensitivity to perfumes or chemicals, etc...
Pain under right rib cage
Insomnia

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Carpal Tunnel Syndrome
Osteoporosis or Osteopenia
Legs or foot cramps at rest
Pain or swelling in joints
Bursitis or tendonitis
Joints pop or crack
White spots on fingernails
Decreased taste or smell

Concerns

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Intense Fatigue
Brain Fog
Memory loss short/long term
Pain or swelling in joints
Stiff joints in morning
Muscle twitching
Unexplained fevers
Headaches/Migraines
Poor concentration
Sore soles of feet in morning

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Body jerks as falling asleep
Restless leg syndrome
Small bumps on back of arms
Heart races
Worrier, anxious
Nosebleeds
Bruise easily
Gums bleed easily
Depressed regularly
Numbness or tingling in body
Loss of muscle tone

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Difficulty falling asleep
Slow starter in the morning
Suddenly dizzy when standing
Difficulty holding chiropractic adjustments
Arthritis
Crave salty food
Headache after exercise
Chronic low back pain
Clench or grind teeth
Perspire too easily
Hives
Bright light hurts eyes
Slow recovery from stress

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Difficulty losing weight
Loss of outer 1/3 eyebrows
Mentally sluggish
Cold hands and feet
Hair loss
Easily fatigued
Seasonal sadness
Low body temperature
Sensitive to iodine
Fast pulse at rest
Nervousness
Sensitivity to cold
Intolerant to heat
Flush easily
Heart palpitations

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Crave sweets
Awaken during night, hard to fall back asleep
Excessive appetite
Crave coffee or sugar in afternoon
Headache if meals are delayed
Get shaky or weak if hungry
Sleepy in afternoon
Fatigue relieved by eating
Afternoon headaches
Irritable before meals

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Shortness of breath with moderate exertion
Opens windows in closed room
Sigh frequently
Bruise easily
Muscle cramps during exercise
Hands and feet go to sleep
Dull pain in chest, worse on exertion

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Pain upon urination
Frequent bladder infections
Cloudy, bloody, or dark urine
Urine has strong odor
History of kidney stones
Pain in low back
Puffy eyes or dark circles under eyes

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Catch colds/flu easily
Runny or drippy nose
Swollen lymph nodes
Gets boils, cysts, styes
Poor wound healing
History of Epstein Bar, Mono, Herpes, Shingles or Chronic Fatigue

	0 = Never	1 = Weekly	2 = Occassionally	3 = Daily
Use of pesticides in home
Use of strong chemicals (bleach, polish, floor wax, window cleaner, etc)
Exposed to tobacco, moth balls, incense, varnish, or dust
Treat home for insects
Use of perfumes, hairspray, cosmetics, nail polish, etc.
Exposed to diesel fumes, exhaust fumes, or gasoline fumes

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Prostate problems
Decreased libido
Urination difficult
Pain or burning with urination
Fatigue
Pain on inside of legs or heels
Feeling of incomplete bowel elimination

	0 = No Symptoms	1 = Mild Symptoms (rarely occurs)	2 = Moderate Symptoms (occurs weekly)	3 = Severe Symptoms (occurs daily)
Painful menstrual cycle
Mood swings around cycle
Painful breasts at cycle
Irregular cycles
Heavy menstrual flow
Acne at menstrual cycle
Yeast Infections
Endometriosis
Uterine fibroids
Fibrocystic breasts
Hot flashes
Vaginal itchiness
Vaginal discharge
Night sweats
Menopausal symptoms