Functional Nutrition Intake Form
Please brew a cup of tea and plan to sit for a moment to complete this form. Because everything is connected.
Full Name
First Name
Last Name
Contact Number
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
History
Age
Birthdate
Heritage (check all that apply)
American Indian/Alaska Native
Asian
Black
Pacific Islander
White
LatinX
Mixed-Race
Other
Prefer not to answer
Principle Language
English
Spanish
Other (please specify)
Birth weight
Birth order (please list ages of biological siblings)
Gender at birth
Pronouns (she/her, he/him, they/them, other)
Gender Identity
Male
Female
Non-binary
Transgender female/woman
Transgender male/man
Another identity
Prefer not to answer
Height
Blood type (if known)
Weight (optional)
Weight one year ago (optional)
Relationship status (check all that apply)
Single
Married or living with partner
Partnered, not living together
Divorced
Widowed
Other
Partner’s pronouns
She/her
He/him
They/them
Other
If you have children, please list their age/ages
Have you or your family recently experienced any major life changes? If so, please comment…
Occupation
Have you traveled outside of the United States? If so, when and where?
Medical Status
Please identify any current or past conditions and add a date for when the condition appeared. In the space below each list, please briefly describe your symptoms, chosen treatment(s), and dates.
Gastrointestinal
Irritable bowel sydrome
Crohn’s
Ulcerative colitis
Gastritis or Peptic Ulcer Disease
GERD (reflux or heartburn)
Celiac Disease
SIBO
Gut Infections
Dysbiosis
Leaky gut
Food allergies, intolerances or reactions
Gallstones
Known absorption or assimilation issues
Other
For issues check, above, please briefly describe your symptoms, chosen treatment(s) and dates for each.
Cardiovascular
Heart attack
Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heartbeat)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
If any issues check, above, please briefly describe symptoms, chosen treatment(s) and dates:
Hormones/Metabolic
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Insulin Resistance or Pre-Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Hashimoto’s (autoimmune hypothyroid)
Grave’s Disease (autoimmune hyperthyroid)
Endocrine Problems
Polycystic Ovarian Sydrome (PCOS)
Infertility
Weight gain
Weight loss
Frequent weight fluctuations
Eating disorder
Menopause difficulties
Hair loss
Other
Please briefly describe your symptoms, chosen treatment(s) and dates for any items check above:
Cancer
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer (melanoma)
Skin cancer (squamous, basal)
Other
Please briefly describe your symptoms, chosen treatment(s) and dates:
Genital & Urinary Systems
Kidney Stones
Gout
Frequent urinary tract infections
Erectile dysfunction or sexual dysfunction
Interstitial cystitis
Frequent yeast infections
Other
Please briefly describe your symptoms, chosen treatment(s) and dates:
Musculoskeletal/Pain
Osteoarthritis
Fibromyalgia
Chronic Pain
Sore muscles or joints, undiagnosed
Other
Please briefly describe your symptoms, chosen treatment(s) and dates:
Immune/Inflammatory
Chronic fatigue syndrome
Rheumatoid arthritis
Lupus SLE
Raynaud’s
Psoriasis
Mixed connective tissue disease (MCTD)
Poor immune function (frequent infections)
Food allergies
Environmental allergies
Multiple chemical sensitivities
Latex allergy
Hepatitis
Lyme (and co-infections)
Chronic infections (Epstein-Barr, cytomegalovirus, herpes, HPV, STIs, etc.)
Other
Please briefly describe your symptoms, chosen treatment(s) and dates:
Respiratory Conditions
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Sleep apnea
Frequent or recurrent colds/flu
Others
Please briefly describe your symptoms, chosen treatment(s) and dates:
Skin conditions
Eczema
Psoriasis
Dermatitis
Hives
Rash, undiagnosed
Acne
Skin cancer (melanoma)
Skin cancer (squamous, basal)
Other
Please briefly describe your symptoms, chosen treatment (s) and dates:
Neurologic/Mood
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Mild cognitive impairment
Memory problems
Parkinson’s disease
Multiple sclerosis
ALS
Seizures
Concussion/Traumatic brain injury
Alzheimer’s
Other
Please briefly describe your symptoms, chosen treatment (s) and dates:
Miscellaneous
Anemia
Chicken pox
German measles
Measles
Mononucleosis
Mumps
Whooping cough
Tuberculosis
Known genetic variants (SNPs, polymorphisms, etc)
Other
Short term memory impairment
Please Select
Yes
No
Sometimes
Shortened focus of attention and ability to concentrate
Please Select
Yes
No
Sometimes
Coordination and balance problems
Please Select
Yes
No
Sometimes
Problems with lack of inhibition
Please Select
Yes
No
Sometimes
Poor organization abilities
Please Select
Yes
No
Sometimes
Problems with time management (late or forget appts)
Please Select
Yes
No
Sometimes
Mood instability
Please Select
Yes
No
Sometimes
Difficulty understanding speech and word finding
Please Select
Yes
No
Sometimes
Brain fog, brain fatigue
Please Select
Yes
No
Sometimes
Lower effectiveness at work, home or school
Please Select
Yes
No
Sometimes
Judgement problems like leaving the stone on, etc
Please Select
Yes
No
Sometimes
Stressful life events
Studies show that past and continued traumas play a significant role in health and health outcomes. Our understanding of your history helps us to best support you through this process and moving forward.
Have you experienced one or more of these stressful life events or traumas in your life? (Check all that apply)
Death of a family member, romantic partner or very close friend because of accident, homicide, or suicide
Sexual or physical abuse by a family member, romantic partner, stranger, or someone else
Emotional neglect or abuse such as ridicule, bullying, put downs, being ignored or told you were no good by a family member or romantic partner
Discrimination
Life-threatening accident or situation)military combat or living in a war zone)
Life-threatening illness
Physical force or weapon threatened or used against you in a robbery or mugging
Witness the murder, serious injury or assault of another person
Is there anything else that you’d like to share about these stressful life events or traumas?
Health concerns
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealt with these concerns in the past?
Doctors
Self-care
Other
Have you experienced any success with these approaches? Please explain
What other health practitioners are you currently seeing? List name and specialtyo below.
Please list the date and description of any surgical procedures you have had (including breast reduction or augmentation, gall bladder removal, and any office procedures).
How much time have you had to take off from work to school for health related reasons in the last year? (Add details if you can)
How often did you take antibiotics in infancy/childhood?
How often have you taken antibiotics as a teen?
How often have you taken antibiotics as an adult?
List any medicine you are currently taking:
List all vitamins, minerals, herbs and nutritional supplements you are now taking:
Nutritional Status
Which of the following foods do you consume regularly?
Soda
Diet soda
Refined sugar
Alcohol
Gluten (wheat, rye, barley)
Fast food
Dairy (milk, cheese, yogurt)
Coffee
Are you currently on a special diet?
Autoimmune paleo (AIP)
SCD/GAPS
Dairy restricted or dairy- free
Vegetarian
Vegan
Paleo
Blood type
Raw
Refined sugar-free
Gluten-free
Ketogenic diet
Intermittent fasting
Other (please describe)
What percentage of your meals are home-cooked?
10
20
30
40
50
60
70
80
90
100
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom:
Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? Do you have any known food allergies or sensitivities? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods such a fatigue, muscles aches, sinus congestion, etc? If so, please explain:
Are there any foods you crave? If so, please explain:
Describe your diet at the onset of your health concerns:
Do you have any known food allergies or sensitivities?
Is there anything else I should know about your current diet, history or relationship to food?
Intestinal Status
Bowel movement frequency
1-3 times per day
More than 3 times per day
Not regularly every day
Bowel movement consistency
Soft & well formed
Often float
Difficult to pass
Diarrhea
Thin, long or narrow
Small and hard
Loose and watery
Alternating between hard and loose
Bowel movement color
Medium brown
Very dark or black
Greenish
Blood is visible
Variable
Yellow, light brown
Chalky colored
Greasy, shiny
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Have you ever had food poisoning? If yes, please describe in detail, including 1) where were you 2) what did you treat it with and 3) if you feel like you fully recovered from it:
Potential Health Hazards
To your knowledge, have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do odors affect you?
Are you or have you been exposed to second-hand smoke?
Are you currently or have you been exposed to mold? (If so, what is/was the source of the exposure and for how long have you been/were you exposed to mold, if known?)
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
How long since you last visited the dentist? What was the reason for that visit?
In the past 12 months has a dentist or hygienist talked to you about your oral health, blood sugar or other health concerns? (Explain)
What is your current oral and dental regimen? (Please note whether this regimen is once or twice daily or occasionally and what kind of toothpaste you use.)
Do you have any mercury amalgams? (If no, were they removed? If so, how?)
Have you had any root canals? (If yes, how many and when?)
Do you have any concerns about your oral or dental health? (Gums bleed after flossing, receding gums)
Is there anything else about your current oral or dental health history that you’d like us to know?
Sleep History
Are you satisfied with your sleep?
Do you stay awake all day without dozing?
Are you asleep (or trying to sleep) between 2:00am and 4:00am?
Do you fall asleep in less than 30 minutes?
Do you sleep between 6 and 8 hours per night?
Is there anything else you would like us to know about your sleep?
Reproductive Hormone History
If you do not have female reproductive organs please skip to the next section - Mental Health Status
How old were you when you first got your period?
How are/were you menses? Do/did you have PMS? Painful periods? If so, explain.
In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Have you/do you still take birth control pills: If so, please list length of time and type.
Have you had any problems with conception or pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here
Mental Health Status
How are your moods in general? Do you experience more anxiety, depression or anger than you would like?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
At what point in your life did you feel best? Why?
Other
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Who in your family or on your health care team will be most supportive of you making dietary change?
What role does spirituality play in your life?
Please describe any other information you think would be useful in helping to address your health concern(s):
Should be Empty: