Client intake form*

If you chose to do the pH assessments … for best results, please do not eat 2 hours prior to the Whole Body Wellness Assessment appointment. We will be taking a urine analysis at the beginning of the appointment. Sipping on water before hand is allowed.

Nutritional Data:

How much of the following do you consume? (example 1D=1/day, 2W=2/week, 3M=3/month)

Timing

Movement

Sleep

Eliminations: (see Bristol Stool Chart below)

Please indicate the most descriptive number(s) of you elimination(s) using the Bristol Stool chart provided.

Females:

Supplements/Medications:

Medical History:

Naturopathic history: