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)




Eliminations: (see Bristol Stool Chart below)

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


Menstrual Cycle
How would you describe the color of your menses?


Medical History:

Naturopathic history:

Please check all with which you are familiar with: