Intake Form

Download the Client Intake Form to fill out at your convenience.

In-depth Client Intake Form

The investment for this 2-part process is $175

To help solve your health challenges through food and lifestyle modifications, I need to know your unique story. Your bio-individuality, such as family history, and the main events in your life that have shaped who you are, beyond food choices.

Maybe that little bump on your head years back triggered a series of health issues shortly after. Or living near that apple farm for two years, where pesticides were sprayed affected your nervous system.

This is where you begin to connect the dots between your health and events in your life. Our sessions will be based on this information. Take your time and make a cup of tea while filling it out.

How it works

Part One

Download the interactiv pdf of the Client Intake Form or complete the form below (same questionnaire)
Email the completed form back to me
Schedule your 90-Minute Review Session on my calendar
We’ll review your information by phone or online

Part Two

I create a timeline based on the information from your intake form
We modify this timeline as we work together
You’ll receive a Functional Nutrition Matrix that captures your symptoms and experiences
You’ll be able to share this timeline with your doctors too!

If you have any questions please email me. The secure PayPal payment can be made on my purchase page.

Thank you!

Confidential Client Information
Name
First Last
Email*
How often do you check email?*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone (day)
Phone (cell)
Phone (night)
Referred by
Statistics
Age*
Birth Date
MM slash DD slash YYYY
Gender
Height
Blood Type
Birth Weight (if known)
Current Weight
Ideal Weight
Weight One Year Ago
Would you like your weight to be different?
If so, what?
Family/Living Situation
Children. If so, how many?
Occupation
History
Have you lived or traveled outside of the United States? If so, when and where?
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you had to take off from work or school in the last year?
- 0 to 2 days
- 3 to 14 days
- more than 15 days
Did you experience any childhood truama (emotional, physical, family/divorce) and or any serious health concerns?
Health Concerns
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealt with these concerns in the past?
- doctors
- self-care
Have you experienced any success with these approaches?
What other health practitioners are you currently seeing? List name, specialty and phone # below:
Please list the date and description of any surgical procedures you have had:
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?
List any medicine you are currently taking:
List all vitamins, minerals, herbs and nutritional supplements you are now taking:
Have any other family members had similar problems (describe)?
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 food allergies or sensitivities?
Which of the following foods do you consume regularly?
- alchohol
- coffee
- dairy (cheese, milk, yogurt)
- diet soda
- fast food
- gluten (wheat, rye, barley)
- refined sugar
- soda
Are you currently on a special diet?
- autoimmune paleo (AIP)
- SCD/GAPS
- dairy restricted or dairy-free
- vegetarian
- vegan
- paleo
- blood type
- raw
- refined sugar-free
- gluten-free
What percentage of your meals are home-cooked?
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100
Is there anything else I 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
- thin, long and 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
- greasy, shiny
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Have you ever had food poisoning? If yes, please describe in detail, including 1) Where were you 2) What did you treat it with and 3) If you feel like you fully recovered from it:
Medical Status
Please check any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates in the box below:
- Cancer
- Heart Disease
- Hepatitis
- Venereal Disease
- Diabetes
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Thyroid Disease
- Depression
- Asthma
- Allergies
- Anemia
- Chronic Yeast Infections
Briefly describe your symptoms, chosen treatment(s), and dates for above list:
Health Hazards
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do odors affect you?
Are you or have you been exposed to second-hand smoke?
Do you have mercury amalgam fillings?
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 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 sleep between 6 and 8 hours per night?
For Women Only
How are/were your menses? 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.
Sexual History
Do you have any concerns or issues with your sexual functioning that you’d like to share with us (pain with intercourse, dryness, libido issues, erectile dysfunction)?
In the past year, have your sexual partners been men, women, or both? And how many partners have you had in the past year?
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.
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 dietary change?
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?
Though it may seem odd, please consider why you might want to achieve that for yourself:
Forms of relaxation
What kind of relaxation techniques do you use? Are breathing, mediation, journaling, yoga etc. involved?
What role do sports and exercise play in your life?
Food
Foods you eat for breakfast
Foods you eat for lunch
Foods you eat for dinner
Are there any foods that you avoid because of the way they make you feel? If yes, explain.
What percentage of your foods are home cooked?
Are you currently on a special diet? If so, explain.
Are you willing to or interested in preparing more meals from home?
Where do you get the rest of your meals from?
How many hours pass between your main meals?
Do you crave sugar, coffee, cigarettes or have any major addictions?
Anything else you would like to share?
Are you willing to move outside of your comfort zone, try new foods and make adjustments in your routines in order to achieve your health goals?
Other
What are three goals you have towards health?
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 dietary change?
Buy the Health Coach Consultation*

Thank you for taking the time to fill out this form and for your payment!

I look forward to talking soon.

Intake Form

In-depth Client Intake Form

The investment for this 2-part process is $175

How it works

Part One

Part Two

Confidential Client Information

Statistics

History

Health Concerns

Nutritional Status

Intestinal Status

Medical Status

Health Hazards

Lifestyle History

Sleep History

For Women Only

Sexual History

Mental Health Status

Other

Forms of relaxation

Food

Other