Client Intake Form

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SERVICES
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- SKIN CARE
BLOG
INTAKE FORMS
- CLIENT INTAKE FORM
- THERMOGRAPHY FORMS
CONTACT

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YOGA
SERVICES
ABOUT
SHOP
- SKIN CARE
BLOG
INTAKE FORMS
- CLIENT INTAKE FORM
- THERMOGRAPHY FORMS
CONTACT

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Client Intake Formteam2023-09-11T15:30:57-05:00

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.

Full name *

DOB *

Address *

City *

State *

Phone Number *

Email *

Reason for visit (prioritized) *

Nutritional Data:

How many ounces of water per day? *

What kind? *

What other kinds of beverages? *

Do you use artificial sweeteners? *

If so, which ones? *

How often, and in what? *

Do you eat breakfast *

If so, what?

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

Fresh fruit *

Raw vegetables *

Fermented foods *

Fast foods *

Meat *

Eggs *

Dairy *

What do you crave? *

What foods do you dislike the most? *

Why? *

Timing

What is the first thing you do when you get up in the morning? *

What time do you eat your first meal? *

What time do you eat your last meal? *

Which meal is your largest of the day? *

Describe a typical 'largest meal' *

Movement

Do you exercise/move/participate in fun sweaty activity? *

If yes, how often? *

Do you look forward to it? *

How do you feel when you are finished? *

Sleep

What time do you go to bed? *

How long do you sleep? *

Do you wake often? *

If yes, why and what time(s)? *

Do you feel rested when you wake up for the day? *

Do you have pain when you first get up? *

If yes, where? *

Does it go away upon moving? *

Eliminations: (see Bristol Stool Chart below)

Do you have daily bowel movements? *

If yes, how many per day? *

If no, please describe your elimination pattern *

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

BSC # *

Color *

Females:

Are you post-menopausal?

If yes, what age did you enter menopause?

What were the characteristics of your menopausal experience?

Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?

Are you now, or in the near future, planning to become pregnant?

Menstrual Cycle

Regular

Shorter than 28 days

Longer than 28 days

N/A

Is your flow longer or shorter than 5 days?

Cramps or clotting?

How would you describe the color of your menses?

Red

Purple

Brown

N/A

Do you experience PMS, Cyclical headaches, or Cravings?

Supplements/Medications:

Do you take any supplements? *

If yes, what do you take, how often, and why? *

Do you take any OTC medications routinely (such as Aleve, Aspirin, or Ibuprofen)? *

If yes, what do you take, how often, and why? *

Do you take prescription medications (prescribed by a licensed medical professional)? *

If yes, what do you take, how often, and why? *

Medical History:

Have you had any surgeries? *

If yes, what and when? *

Have you received any diagnoses from licensed medical professionals? *

If yes, what and when? *

Naturopathic history:

Have you ever been in consultation with a naturopath? *

If yes, why and how long ago? *

What was suggested?

Did you experience a good outcome? *

What did you like about it? *

What wasn't as successful for you? *

Do you have regular adjustments with a chiropractor? *

Do you have regular body work/massages? *

Please check all with which you are familiar with:

Homeopathy

Back Flowers/flower remedies

Probiotics

Aromatherapy

Muscle Response testing

Herbals

Sports nutrition

Digestive Food Enzymes

None

Terms & Agreement *

By checking this box, I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling, I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, as an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease.

By signing below, I certify that I have read and understand the statements above *

Please Enter Today's Date *

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Contact Us

125 South Main Street
West Point, NE 68788

135 North 15th Street
Ord, NE 68862

402.372.1016
thegoodearthcompany7@gmail.com

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