New Client Intake

Name

Year you were born

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 any concerns with your digestive health? ANSWER YES OR NO

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

Upload any relevant medical records or labs you would like for me to review.