New Client Intake

Name

Age

Phone

Format: (000) 000-0000.

Email

example@example.com

Reason for your visit

How many ounces of water do you drink in a day

What other beverages and how much

Please list how often you eat each food item below

D= Day, W=Week, M=Month, N=Never

example 1XW would be 1 time a week

Dairy products

Fruits & Veggies

Red Meats

Fermented foods

What do you crave

Do you have daily bowel movements

If yes how many per day

Color & BSC #

Do you take any supplements

Do you take any OTC medications routinely such pain reliever 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 licensed medical professionals? If so, what and when?

I understand that this consultation is focused on holistic wellness, emphasizing the connectionbetween brain and gut health. I acknowledge that the information provided is for educational andwellness purposes only and not intended as a medical diagnosis or treatment.

Date

Appointment Request- you will be contacted to confirm this date/time is available