Heirloom Wellness Intake Form
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
What is your primary goal for seeking Genomics and Wellness Coaching? When you achieve your goal, what would that look like for you?
*
Date of Birth
*
-
Month
-
Day
Year
Date
Height
*
Current Weight
*
Ideal Weight
*
Have you or your family recently experienced any major life changes? If so, please comment. ?
Health Concerns
What are your main health concerns? (Describe in detail, including the severity of the symptoms and any prior diagnoses related to these concerns). ?
*
Have any other family members had similar problems (please describe)?
When did you first experience these concerns?
*
How have you dealt with these concerns in the past?
*
Self medicated, Doctors, Other
Have you experienced any success with these approaches?
*
Self medicated, Doctors, Other
How much time have you had to take off work or school in the last year:
0-2
More than 15 days
3-14
Other
Are you under the care of any other health or wellness providers?
*
Please list the date and description of any surgical procedures you have had (including elective/cosmetic).
Procedure
Date
Description
1
2
3
4
5
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?
*
Do you take any medications currently?
Name
Frequency
Dosage
Duration
Comments
1
2
3
4
5
Current Supplementation:
Name
Frequency
Dosage
Duration
Comments
1
2
3
4
5
Back
Next
Save
Back
Save
Continue
Continue
Next
Nutritional Status
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? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain:
Are there foods that you crave? If so please explain:
Describe your diet at the onset of your health concerns:
Do you have any known or suspected food allergies or sensitivities?
Have you had prior food sensitivity testing?
Yes
No
Which of the following foods do you consume regularly?
Soda
Diet Soda
refined sugar
alcohol
fast food
gluten (wheat, rye, barley)
dairy (milk, cheese, yogurt)
coffee
Are you currently on a special diet?
Autoimmune paleo (AIP) paleo
SCD/GAPS
dairy restricted or dairy-free raw
vegetarian
vegan
paleo
blood type
refined sugar-free
gluten-free
other
If you checked "Other" from the question above, please describe in more detail here.
What percentage of your meals are home-cooked? Please describe.
Is there anything else we 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 but not 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:
Medical Status
Gastrointestinal - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Irritable Bowel Syndrome
Crohn’s
Ulcertative 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
Cardiovascular - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Heart attack
Heart Disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heartbeat)
Hypertension (high blood pressure)
Rheumatic Fever
Mitral Valve Prolapse
Other
Hormones/Metabolic - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Type 1 Diabetes
Type 2 Diabetes
Type 2 Diabetes
Metabolic Syndrome
Insulin Resistance or Pre-Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Hashimoto’s (autoimmune hypothyroid)
Grave’s Disease (autoimmune hyperthyroid)
Endocrine problems
Polycystic Ovarian Syndrome (PCOS)
Syndrome (PCOS)
Infertility
Weight gain
Weight loss
Frequent weight fluctuations
Eating disorder
Menopause difficulties
Hair loss
Other
Cancer - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Lung Cancer
Breast Cancer
Colon Cancer
Ovarian Cancer
Prostate Cancer
Skin Cancer (Melanoma)
Skin Cancer (Squamous, Basal)
Other
Genital & Urinary Systems - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Kidney Stones
Gout
Erectile Dysfunction or Sexual Dysfunction
Interstitial Cystitis
Frequent urinary tract infections
Frequent Yeast Infections
Other
Musculoskeletal/Pain - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Osteoarthritis
Fibromyalgia
Chronic Pain
Sore muscles or joints, undiagnosed
Other
Immune/Inflammatory - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Chronic Fatigue Syndrome
Rheumatoid Arthritis
Lupus SLE
Raynaud’s
Psoriasis
Mixed Connetive 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, Cytomegalo-virus, Herpes, etc.)
Other
Respiratory Conditions - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Asthma
Chronic Sinusitis
Bronchitis
Emphysema
Pneumonia
Sleep Apnea
Frequent or recurrent Colds/Flus
Other
Skin Conditions - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Eczema
Psoriasis
Dermatitis
Hives
Rash, undiagnosed
Acne
Skin Cancer (Melanoma)
Skin Cancer (Squamous, Basal)
Other
Neurologic/Mood - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Depression
Anxiety
Bipolar Disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Mild Cognitive Impairment
Memory problems
Memory problems
Multiple Sclerosis
ALS
Seizures
Alzheimer’s
Other
Miscellaneous - Please list any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
Symptoms
Chosen
Treatment(s)
Dates
Past
Now
Anemia
Chicken Pox
German Measles
Measles
Mononucleosis
Mumps
Sleep Apnea
Whooping Cough
Tuberculosis
Known genetic variants (SNPs, polymorphisms, etc)
Other
Please check frequency of the following:
Yes
No
Sometimes
Short term memory impairment
Shortened focus of attention and ability to concentrate
Coordination and balance problems
Problems with lack of inhibition
Poor organization abilities
Problems with time management (late or forget appts)
Mood instability
Difficulty understanding speech and word finding
Brain fog, brain fatigue
Lower effectiveness at work, home or school
Judgment problems like leaving the stove on, etc
Health Hazards
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do chemicals or synthetic fragrances affect you?
Are you or have you been exposed to second-hand smoke?
Oral Health History
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?
Do you have any concerns about your oral or dental health?
Is there anything else about your current oral or dental health or health history that you’d like us to know?
Lifestyle History
Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time.
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
How do you handle stress?
Sleep History
Are you satisfied with your sleep?
Do you stay awake all day without dozing?
Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.?
Do you fall asleep in less than 30 minutes?
Do you fall asleep in less than 30 minutes?
For Women Only
How are/were your cycles? 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.
1
2
3
4
5
6
7
8
9
10
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 you family or on your health care team will be most supportive of you making lifestyle/dietary changes?
Please describe any other information you think would be useful in helping to address your health concern(s):
What are your health goals and aspirations?
What will this goal do for you?
Is there anything that will get in the way of following a treatment plan in order to achieve results?
Client Agreement & Liability Waiver I, the undersigned, understand that the wellness services provided by Bioalchemy Wellness, including but not limited to genetic wellness coaching, herbal recommendations, holistic wellness strategies, and energy healing practices such as Reiki and Manual Lymphatic Drainage (MLD), are intended for educational and informational purposes only. I acknowledge that: Not a Substitute for Medical Advice: The services provided do not diagnose, treat, or cure any medical condition and are not a substitute for professional medical care from a licensed healthcare provider. I understand that I should consult with my physician or other qualified health providers for any medical concerns. Voluntary Participation: My participation in these services is voluntary, and I assume full responsibility for my health and wellness decisions.Personal Responsibility: Any actions or changes I make in my lifestyle, diet, or health practices based on the recommendations given are done of my own volition, and I accept full responsibility for any outcomes that may arise. Results May Vary: I understand that individual results may vary, and no specific results are guaranteed. Release of Liability: I hereby release Bioalchemy Wellness and Leah Vautrot from any and all claims, liability, or damages arising out of my participation in wellness coaching services, including any unintentional harm resulting from my application of suggested protocols. By signing below, I confirm that I have read and understood this waiver and agree to its terms.
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