Wellness Warrior Intake Form

Wellness Warrior Intake Form
Thank you for taking the time to fill out this form and provide details of your health, goals and medical history. My mission is to empower clients to achieve their optimal health in order to perform in every aspect of their life.

This information is confidential and will be used for review only and will not be public knowledge.

I look forward to partnering with you on your journey towards optimal health!

In health,

Adriana Renton R.Kin, FST LII, FRCms
Date Today

MonthDayYear
Date
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Phone Number
Please enter a valid phone number.
Email
example@example.com, no spam emails
Mailing Address to receive the FREE 90 Day Cultivation of Intention Booklet

Street Address

Apartment / Suite

CityState / Province

Postal / Zip Code
Civil Status
Occupation
Emergency Contact Person

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.
Wellness Warrior Goals & Aspirations
What health goals or aspirations brought you to the Wellness Warrior Women's Collective?
What motivates you? (Intrinsic, extrinsic, a schedule, health scare, connection etc.)
What type of learner are you?

VisualSomeone else being successfulAudioKineticOther
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Who in your family or health team will be the most supportive?
What role does spirituality play in your life?
What is your general stress level /10?
How do you mitigate stress? (Anxious, avoidant, listen to music, exercise, remain stressed etc)
Health Information
Height
Weight and Weight one year ago (optional)
Heritage (Asian, Black, Latinx, Mixed-race, Native/Aboriginal, Pacific-Islander, White, Prefer not to say or other...)
If you have children, please list age(s):
What does your current exercise schedule look like in a week?

Health related questions

	Yes	No	Remarks
Do you currently have a broken bone?
Do you have strains or sprains?
Are you using a cane or crutch?

Please indicate any past broken bones and injuries with dates.
Please indicate any past surgeries with dates.
Do you feel any pain or discomfort in your body?

YesNo
Where do you feel the pain?
What part of the body?
How do you describe the pain?

StabbingAchingBurningNumbnessPins & NeedlesOther
What medications are you currently taking? Including intermittently.
What part of the body?
What minerals, vitamins or nutritional supplements are you currently taking?
What part of the body?
What percentage of your meals are home cooked?
What part of the body?
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptoms including allergies or sensitivities.
What part of the body?
Do you have any symptoms immediately after eating such as bloating, gas, sneezing, fatigue, muscle aches, sinus congestion or hives?
What part of the body?
Do you follow any special diet?

Autoimmune paleo (AIP)Blood TypeDairy restricted or dairy-freeGluton-freeIntermittent FastingKetogenic DietPaleoRawRefined Sugar-freeSCD/GAPSVeganVegetarianOther
Are there any foods or food types that you crave?
What part of the body?

Medical Status: Gastrointestinal

	Not Normal	Date/Remarks
Celiac Disease
Crohn's
Dysbiosis
Elimination (Constipation, incontinence)
Food allergies, intolerances or reactions
Gallstones
GERD (reflux or heartburn)
Gut Infections
Irritable Bowel Syndrome
Kidney Stones
Known absorption or assimilation issues
Leaky Gut
SIBO
Other...

Is there anything else you wish to share or discuss about your current diet, history or relationship to food?
What part of the body?
Bowel movement frequency in a day? (1-3/day, 3+/day, not regular every day)
What part of the body?
Intestinal Status:

Soft & well formedLoose but not wateryOften difficult to passAlternate between hard and looseSmall & hardI don't knowOther
Do you experience intestinal gas? If so, how excessive in a day? Is there an odour? Is there pain associated?
What part of the body?
Have you ever experienced food poisoning? If yes, please describe including when, what you ate and if you feel you have fully recovered.
What part of the body?
Are you currently or have you been exposed to second-hand smoke?
What part of the body?
Have you ever been exposed to any chemicals or toxic metals? (Lead, mercury, arsenic, aluminum)
What part of the body?
Are you currently or have you ever been exposed to mold? If so, what was the source, type and for how long?
What part of the body?
How many alcoholic drinks do you have a week? or month?
What part of the body?
Have you ever abused alcohol, drugs, medication, tobacco or caffeine? Do you still?
What part of the body?

Medical Status: Hormones/Metabolis

	Yes	Date/Remarks
Diabetes (Pre-, Type I, Type II)
Eating Disorder
Endocrine Problems
Grave's (autoimmune hyperthyroid)
Hair Loss
Hypoglycemia
Hypothyroidism
Hyperthyroidism
Hashimoto's (autoimmune hypothyroid)
Infertility
Menopause difficulties
Polycyctic Ovarian Syndrome
Weight gain or loss
Other

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?
Do you currently have a period? OR menstruating but use an IUD?
How old were you when you first got your period? How are/were your menses? PMS, painful periods? If so, explain.
If not, when did you start menopause? What symptoms did you experience. Are you still experiencing any symptoms?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list.

Medical Status: Cardiovascular Disease

	Yes	Date/Remarks
Anemia
Angina
Arrhythmia (irregular heartbeat)
Elevated Cholesterol
Heart Attack
Hypertension ( high blood pressure)
Mitral Valve Prolapse
Stroke
Other...

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?

Medical Status: Immune/Inflammatory

	Not Normal	Date/Remarks
Cancer
Chronic Fatigue Syndrome
Chronic Infections (Epstein-Barr, Cytomegalovirus, Herpes, HPV, STI's etc
Environment Allergies
Food Allergies
Hepatitis
Latex Allergy
Mononucleosis
Psoriasis
Rheumatoid Arthritis
Rayneud's
Other...

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?

Medical Status: Musculoskeletal/Pain

	Not Normal	Date/Remarks
Arthritic Joints
Chronic Pain
Fibromyalgia
Osteoarthris
Sore muscles or joints, undiagnosed
Other...

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?

Medical Status:Respiratory Conditions

	Not Normal	Date/Remarks
Asthma
Bronchitis
Chronic Sinusitis
Emphysema
Frequent or recurrent Colds/Flu
Pneumonia
Sleep Apnea
Whooping Cough
Other...

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?
Sleep History: Are you satisfied with your sleep?
Do you have/take any sleep aids? Do you fall asleep in less than 20 minutes?
What time do you typically go to sleep and when do you wake?
Is there anything else you would like share about your sleep?

Medical Status: Neurologic/Mood

	Not Normal	Date/Remarks
ADD/ADHD
Alzheimer's & Dementia
Anxiety
Autism
Bipolar Disorder
Concussion/ Traumatic Brain Injury
Depression
Headaches
Memory Problems
Migraines
Mild Cognitive Impairment
Multiple Sclerosis
Parkinson's Disease
Seizures

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?

Stressful Life Events or Trauma you have experienced:

	Yes	No
Death of a family member or close friend
Discrimination
Emotional neglect or abuse (Ridicule, bullying, put downs, ignored, told you were no good by a family member or romantic partner)
Life-threatening accident or situation (car accidents, combat, war zone)
Life-threatening illness
Sexual or physical abuse by a family member, partner or stranger
Physical Force or weapon threatened or used against you in a robbery or mugging
Witness a murder, serious injury or assault on another person
Other

Briefly describe your symptoms, chosen treatment(s) and dates:
What part of the body?
Family History Illnesses of Mother

CancerCardiovascular DiseaseDiabetes MellitusDementia & AlzheimersHypertensionParkinsonsOther
Family History Illnesses of Father

CancerCardiovascular DiseaseDiabetes MellitusDementia & AlzheimersHypertensionParkinsonsOther
Please describe any other information you think would be helpful in addressing your health concern(s).
Thank you for taking the time to answer and share your health history, goals and aspirations.

Please sign to confirm that all the above information is accurate and true to the best of my knowledge. If there are any changes in my current level of health, I will inform Adriana Renton of my condition. I understand that the Kinesiologist does not diagnose or treat illness or disease and does not prescribe medications. I agree to pay my account with this office in accordance with the regular rate and payment terms. Emergency cancellations will be determined by the practitioner. It is agreed that any claim of liability due to the virtual nature of this educational program is hereby waived.

All information is kept completely confidential.
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Wellness Warrior Intake Form

Patient Information

Wellness Warrior Goals & Aspirations

Health Information