New Client Intake Form
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Full Name
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First Name
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Address
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Street Address
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Postal / Zip Code
Phone Number
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Format: (000) 000-0000.
E-mail
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Top Two Health Goals (explain as needed)
What do you hope to achieve in working together?
What is your current height and weight?
Recent Weight Changes?
Gain
Loss
Stable
If weight has changed recently, how much?
Do you have any diagnosed medical conditions currently? If yes please explain.
Are you currently under a doctor's care?
Yes
No
Have you had recent lab work?
Yes
No
Date of recent lab and what labs were performed? Will you be including results for your consult?
Symptoms Checklist (check all that apply)
Fatigue/low energy
Brain Fog/memmory issues
Digestive issues (explain)
Joint pain/stiffness
Skin Problems (explain)
Headaches/migraines
Sleep problems
Mood changes (anxiety, depression, irritability? explain)
Difficulty gaining or losing weight (explain)
Menstrual or menopausal symptoms
Please add explanation to check list above
How many hours of sleep per night on average?
Do you wake during the night? If yes, how often?
Do you monitor sleep with a sleep App?
Describe a typical day of eating (meals, snack, drinks) and how would you describe your diet? Carnivore, Keto, Vegan, etc..
Do you have any food cravings?
Known food sensitivities or allergies?
How often do you exercise?
Never
1-2x/week
3-5x/week
Daily
Types of exercise and how often of each
Main source of stress and stress level:
Coping strategies for stress:
Coffee/tea (cups/day)
Alcohol? glasses (approximately 4 ounces)/week
Tobacco? yes or no? If yes, type?
Recreational Drugs?
Personal Medical History (check all that apply)
Diabetes
High blood pressure
Heart disease
High cholesterol
Cancer - if yes list type(s)
Thyroid disease - explain
Autoimmune disease - explain
Digestive disorders
Explain
Family History (check all that apply)
Diabetes
High blood pressure
Heart disease
High cholesterol
Cancer - if yes list type(s)
Thyroid disease - explain
Autoimmune disease - explain
Digestive disorders
Explain
Current Prescription Medications
Current Supplements
Bowel Movements
Daily
Every other day
Less Frequent
Stool Consistency
Formed
Loose
Hard
Alternating
Digestive Symptoms
Bloating
Gas
Reflux
Abdominal pain
Are you still menstruating?
Yes
No
Menopausal symptoms if applicable
Hot flashes
Night sweats
Vaginal dryness
Mood
Disrupted sleep
Mold Exposure
Yes
No
Unsure
Use of water filters or RO?
Yes
No
Exposure to chemicals or heavy metals? If yes explain.
On a scale of 1-10, how ready are you to make lifestyle changes?
What do you think might make it hard for you to stick to changes?
Is there anything else you would like to share?
I have answered all questions to the best of my knowledge
I acknowledge that my sessions with Micki Immanivong are intended solely for educational purposes and do not constitute medical advice or a medical diagnosis. I understand that any adjustments I choose to make based on the information provided are my own responsibility and should be discussed with my healthcare provider. I release Micki Immanivong from any liability regarding actions I take as a result of what I learn during our sessions.
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My Products
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Root Discovery w/DNA
$897.00
$
897.00
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2
3
4
5
6
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Root Discovery without DNA
$550.00
$
550.00
Quantity
1
2
3
4
5
6
7
8
9
10
Rooted Restoration (3 months) w/DNA
$1,997.00
$
1,997.00
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1
2
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4
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6
7
8
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Rooted Restoration (3 months) without DNA
$1,629.00
$
1,629.00
Quantity
1
2
3
4
5
6
7
8
9
10
Deep Roots Mentorship (6 months) w/ DNA
$3,795.00
$
3,795.00
Quantity
1
2
3
4
5
6
7
8
9
10
Deep Roots Mentorship (6 months) without DNA
$3,445.00
$
3,445.00
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4
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6
7
8
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10
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