Initial Intake Form
So tell me about yourself!!!
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
AGE
DOB
HEIGHT
CURRENT WEIGHT (INCLUDE HIGHEST & LOWEST WEIGHT IN PAST FEW YEARS)
OVERALL WEIGHT GOAL
WHAT IS YOUR OVERALL GOAL FOR YOUR PERSONAL HEALTH & WELLNESS?
WHAT TIME OF DAY WORKS BEST FOR OUR SESSIONS?
DO YOU PREFER OUR SESSIONS BE HELD PHONE/ZOOM/SKYPE/OTHER?
OCCUPATION
WHAT ARE YOUR MAIN HEALTH CONCERNS RIGHT NOW?
WHY IS THIS IMPORTANT TO YOU?
WHAT HAS WORKED & NOT WORKED IN THE PAST?
PLEASE DESCRIBE YOUR FAMILY (PATERNAL & MATERNAL) HEALTH HISTORY?
PLEASE DESCRIBE YOUR OWN HEALTH HISTORY?
DATE OF LAST BLOODWORK & OUTCOME?
LIST OF CURRENT MEDICATIONS & AMOUNTS
LIST OF CURRENT SUPPLEMENTS, BRAND NAME & AMOUNTS
What percentage of your current diet is organic?
What percentage of your household regimen is organic and limited to toxin-free products? (Household, Beauty, Other)
Do you live alone?
Have you experienced any major life changes recently? (death, divorce, job change, moving, etc)
Please describe in detail what a typical daily diet looks like (include: beverages & condiments):
How often do you take antibiotics on average yearly?
Describe your morning and evening routine:
Describe your sleeping pattern & average hours you sleep per night:
How many cups of water do you drink on average daily? (What other types of liquids do you consume?):
What type of water do you consume mostly? (ex: plastic bottled water, reverse osmosis, etc.)
Do you smoke? (If yes, please describe/amount):
Do you drink? (If yes, please describe/amount):
Do you have any food allergies, or food intolerances? (If yes, please describe):
What do you do for fun & relaxation/ How often do you engage in these activities?
Rate your stress level on a daily basis 1-10 (10 being the highest):
Describe your exercise regimen:
Describe your digestive health (ex: how many BM's, formed, bloated, gas, heartburn, etc):
How many times per week do you eat out?
Do you cook? Describe a few things you cook/prepare for yourself?
What are your biggest challenges when it comes to cooking more?
Describe how you would imagine feeling living your healthiest self? What might you do more of?
How important is it to ACHIEVE your health goals?
Back
Next
Save
ONLY APPLICIBLE- IF CHECKING FOR POSSIBLE COVERAGE OF "THE INFINITE ALLERGY RESEARCH LABS" FOOD INTOLERANCE/ALLERGY TEST. Please provide the following: Name of insurance company; Subscriber number; Group number; Primary person insured and their DOB:
Save
Submit
Should be Empty: