Initial Intake Form

Initial Intake Form

Phone: 512-790-0692 Email: office@MeganGump.com
Dear Client,

Welcome! And thank you for choosing Megan Gump to help you.

HOW THE PROCESS WORKS:

STEP 1:

During your initial consultation, Megan will review your health history and make recommendations for diet, lifestyle, and lab tests that are appropriate for your age, sex, and health history.

STEP 2:

Once you have completed your lab tests, Megan will explain the meaning of your test results to you in a follow-up consultation. She will create recommendations for you including diet changes, nutritional supplements, and exercise, lifestyle, and stress management advice.

STEP 3:

Subsequent consults are scheduled to monitor your progress.

We invite you to contact us via email or phone should you have any questions during the course of your journey.

We look forward to helping you in achieving your current wellness goals and guiding you in maintaining wellness throughout your life.

Megan does not treat or diagnose any disease. Megan's work is to help support physical and chemical stress imbalances, with the goal of promoting wellness. Consulting with Megan does NOT create a “doctor-patient” relationship and she is not “treating” you.

In Health,

Megan Gump, CFMP, FNTP
New Client Paperwork

I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my protocol, any fees for professional services rendered to me will be immediately due and payable. If a card is on file, it will be charged to get your due payment to a zero balance. I authorize Megan Gump to release my personal health information to me.
Name Regarding Services:*

First NameLast Name
Today's Date:*

MonthDayYear
Date
Shipping Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Best Phone Number:*

Area CodePhone Number
Do you prefer Zoom or a phone call?
Age:*
Birthdate: *

MonthDayYear
Date
Sex:*

FemaleMale
Relationship Status:

MarriedSingleWidowDivorced
Number of Children:*
Height:
Current Weight:
Desired weight range?
Occupation:*
How many hours do you work per week? *
How you found Megan or Referred by:
What are your hobbies/activities?
What is your major health concern? *
Other concerns?
What makes you feel better?
How does your condition affect you?
What do you feel needs to happen for you to get better?
What are your main sources of stress? *
How do you deal with stress? *
Please scroll through and complete the ACE Questionnaire. Be sure to write down your score.
What is your ACE Score?
Please list any GI symptoms you have experienced in the last year (gas, bloating, diarrhea, constipation, stomach cramping/pain, stools hard to pass): *
Do you have a Gallbladder?*

YesNo
Do you sleep well?
Do you wake up during the night? What time(s) if yes?
What time do you go to bed?
What time do you generally wake up?
How do you feel when you wake up?
What are your overall health goals once your complaints are resolved?
How long has it been since you really felt good?
Check off any of the following that have applied to you in the last 6 months:

FatigueWeaknessAchesMuscle CrampsUnusual PainIce Pick PainHeadacheLight SensitivityRed EyesBlurred VisionTearingSinus ProblemsCoughShortness of BreathAbdominal PainDiarrheaJoint PainMorning StiffnessMemory IssuesFocus/Concentration IssuesWord Recollection IssuesDecreased Learning of New KnowledgeConfusionDisorientationSkin SensitivityMood SwingsAppetite SwingsSweats (especially night sweats)Temperature Regulation or Dysregulation ProblemsExcessive ThirstIncreased UrinationStatic ShocksNumbnessTinglingVertigoMetallic TasteTremors
Do you smoke (tobacco or cannabis)? If yes, how much/how often?
Are you exposed to second hand smoke?
What kind of water do you drink? (Spring water, tap water, Fridge filter, Berkey, etc)
How much water do you drink per day?
Do you drink caffeinated drinks? If yes, how much/how often?
Do you drink alcohol? If yes, how much/how often?
Do you drink soda (diet or regular)? If yes, how much/how often?
Do you live in a new home build or somewhere with new carpet, new cabinets, new paint, etc?
What is your relationship to plastic? Drink from plastic water bottles, use plastic Tupperware, etc?
Do you use any products with synthetic fragrances (scented garbage bags, dryer sheets, fabric softeners, laundry detergent, dish soap, hand soap, air freshener, cologne, perfume, candles, anything else scented...)? WHICH ones?
Have you had any exposure to man-made chemicals that you know of (vaccines, cleaning chemicals, toxic metals, farm chemicals, hair care products, insecticides, paints and solvents, auto chemicals, welding, etc)? Please explain:
Do you have carpet in your house? If YES, where?
Do you have a gas furnace or stove/oven?
Do you have implants (silicone or other)?
Have you ever had water damage in your current living location?
Have you had a mold issue before?
Have you had your wisdom teeth removed?
Have you had any other dental procedures done i.e. fillings, root canals, pulled teeth, crowns, etc.?
Do you have amalgam (silver) fillings?

YesNo
If YES, How many fillings do you have?
Do you chew gum?

YesNo
How many times do you go to the dry cleaners in a year?
Currently are you bothered by any exposures like chemicals, fumes, cigarette smoke, perfumes, car exhaust, etc? Please explain:
What role does exercise play in your life?
Do you have any allergies?
Are you currently taking any vitamins/minerals/herbs/homeopathic remedies, prescription/non- prescription medications, aspirin, laxatives, diet pills, or any other supplements? Please list all below:
Do you have any known allergies to medications or herbs? Please list all:
Are you currently under a practitioner’s care for a specific health issue?
If so, what treatments are you undergoing?
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and date:
What were your eating habits like as a child? (List types of foods)
Have you ever been or are currently a vegetarian or vegan? IF SO, how long?
List your normal breakfast, lunch and dinner.
What percent of your diet is Organic?
What percentage of your food is home cooked?
How often do you eat out?
What are the three worst foods you eat each week?*
What are the three healthiest foods you eat each week?*
Do you crave sugar?
Do you crave salt?
Do you feel tired, bloated, and/or gassy after meals?
How is your energy level?
Do you have and use WiFi? If so where is the router located?
Do you turn off WiFi at night? Or have you turned down the power output settings?
Do you use and/or sleep with a fitbit, apple watch, or other wearable EMF-emitting technology?
Where do you hang out? Anywhere with lots of electricity (casinos, shopping malls, schools, universities, etc.)?
Do you use electrically-powered workout equipment such as a treadmill?
How often/long do you talk on a cell phone? Do you put the phone directly to your head?
Do you have technology in your bedroom? (Cell phones under your pillow, alarm clocks near your head, use laptop in bed, etc?) Explain...
Do you feel your libido is adequate?

YesNo
Family Health History (Please check all that apply):

DiabetesHeart DiseaseArthritisKidney DiseaseAsthmaAutoimmune DiseaseGallbladder DiseaseCancer
Do you enjoy daily activities?
Do you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc.?
Do you notice feeling more agitated/irritable than previously?
Do you have fun in life?
Women Only Section
Do you have breast implants?
Age of your first period:
Are your periods regular?
How Frequent?
Number of pregnancies:
When was your last period?

MonthDayYear
Date
How many children have you delivered and how were they born (vaginally or by cesarean)?
Did you receive antibiotics during labor?
Have you ever had a miscarriage or an abortion?
Male Only Section
Approximate age of onset of puberty:
Do you wake at night to urinate?
How many times per night?
Do you have any difficulty and/or pain with urination?

YesNo
Previous Lab Results
Please upload any previous lab results within the last year. Nothing older than one year will be reviewed. Lab Results can also be emailed to office@megangump.com
Upload File
Upload File
I clearly understand and agree that all services performed are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate services, any outstanding charges will be immediately due and payable.
Type your full name to agree to the terms and conditions:
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You are awesome! :)
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Initial Intake Form

Women Only Section

Male Only Section

Previous Lab Results