General Information Name: Telephone Home: Work: Cell: Mailing Address: Client Intake Form Date: Email: How would you prefer to be contacted? Who referred you? Gender: M F Date of Birth: Primary Doctor: Ph: Email: Occupation: Reason(s) for visit in order of importance: 1. 2. 3. 4. 5. Emergency Contact: Ph: Daily Lifestyle Hours in a regular work week: Do you like your job? When is usual rising time? How do you sleep? Activity level and work conditions (check all that apply): Sitting mixture sitting and walking Lifting/carrying driving computer fluorescent lights outside other: When is usual bedtime? Do you use an alarm to wake up? Do you need to take naps during the day? 1
List your regular physical exercise: How many days per week do you exercise? Average duration of exercise: How often do you perform hobbies/recreation? List hobbies/recreational activities: Rate your stress level on a scale of 1-5, with 1 being negligible and 5 being severe: Do you use any recreational drugs? If so, please describe type and how often: List any surgeries you have had below: Year of surgery Medication Dosage Length of Time on Med 2
General Questions 1) Do you have amalgam (silver) fillings? How many? 2) When was the last time you were on a course of antibiotics? a.why were you prescribed them? 3) How often do you have a bowel movement? 4) Any problems with bowel movements (constipation, diarrhea, black stool, undigested food in stool, gray in color, fatty looking)? 5) Do you have any seasonal allergies? To what? Since when? 6) Rate your energy level during an average day, with 1 being unable to get out of bed and 10 feeling like you could run a marathon: 1 2 3 4 5 6 7 8 9 10 7) Are you exposed to any harsh chemicals at work (cleaning, painting, new carpeting, etc.)? Please describe: 8) Were you born vaginally or cesarian section? 9) Were you breast or bottle fed? If breast, until what age? 10) Were you diagnosed with ADD/ADHD as a child or adult? Do you take medication for it? Please describe: 11) Have you traveled out of the country within the past year? Nutrition, Food, and Lifestyle On average, how many times per week do you: Cook full meals at home? Eat breakfast? Shop for food? Eat in the car? Eat and work simultaneously? Eat meat? Use plastic containers for food storage? Re-heating? 3
12) Do you frequently use any of the following medication? Please circle all that apply. Antacids Antibiotics Aspirin/Ibuprofin/NSAIDs Laxatives Stool softeners Cortisone/prednisone 13 ) Do you frequently consume any of the following? Please circle all that apply. Alcohol Coffee Luncheon meats Candy Energy drinks Margarine Chewing tobacco Fast food Sweets/pasteries Cigarettes Fried food 13) Do you drink energy drinks? What kind? How often? 14) Do you drink sodas? How often? 15) How much water do you drink per day (circle one)? I always have water with me A few glasses Not that often- when I remember to hardly ever- I don t like water 16) What type of water do you drink (tap, bottled, reverse osmosis, de-ionized, filtered)? 17) Please describe an average breakfast: 18) Please describe an average lunch: 19) Please describe an average dinner: 20) Do you eat snacks? How often? Describe an average snack: Almost done! Keep going! All of this information will help us in the longrun! 4
21) Please circle all that apply to your eating patterns: Emotional eater forget to eat hungry all of the time Eat out of boredom No joy in eating live to eat instead of eat to live eat out of necessity Don t know when to stop cravings love well prepared food Quantity over quality healthy eating habits I don t eat enough Comments on eating patterns: 22) Do you have known food allergies? What are they? Describe the reaction: 23) What popular diets have you tried (Atkins, Zone, Paleo, etc.)? How long? Did you like it? 24) Where do you usually shop for food? 25) How many members in your family? 26) What is your weekly budget for food (please circle): <$50 $50-100 $100-150 $150-200 >$200 27) What style of mentor do you prefer (please circle one): Drill sergeant Nurturing Tough love Hold accountable 28) Any additional comments (really, anything you want me to know): Thank you!!! 5