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Holistic Client Wellness Assessment Intake Form

 

 

Name ____________________________________________________________  Age ________

Telephone (best) _____________________ Email _____________________________________

Eye Color:   Blue____   Green_____   Hazel/Mixed_____    Brown_____

 

Reason for visit (prioritized):

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

 

Nutritional data:

How many ounces of water per day? ________ What kind? ________________________________

What other beverages and how much? ______________________________________________

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)

 

Fruit _____ Vegetables _____ Eggs _____ Dairy _____ Fermented food _____ Fast food ___ 

Chicken _____ Fish _____ Red Meat _____ Pork _____ Meat Alternatives _____

 

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? ____________ Last meal? _________________________

Which meal is your largest of the day? ______________________________________________

Describe a typical largest meal. ____________________________________________________
______________________________________________________________________________

 

Movement:

Do you exercise/move/participate in fun, sweaty activities? If so, what and 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 up often? __________

If so, why and at what time(s)? ____________________________________________________

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

Do you have pain when you first get up? __________ If so, where? _______________________ ______________________________________________________________________________

Does it go away upon moving? ____________________________________________________

 

Eliminations:

Do you have daily bowel eliminations? __________ If yes, how many per day? ______________

If no, please describe your elimination pattern. _______________________________________ ______________________________________________________________________________

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

BSC # _______________ Color ________________________________________

 

Females:

Are you post-menopausal? ________ If yes, at 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? _______________________

Is your menstrual cycle regular? _________ Longer than 28 days? ________ Shorter? ________

Is your flow longer or shorter than 5 days? ___________________________________________

Do you have cramps or clotting? ________ Would you describe the color of your menses as bright red, dark purple, or brown? _________________________________________________

Do you experience PMS, cyclical headaches, or cravings? _______________________________

 

Supplements/medications:

Do you take any supplements? ________ If so, what, how often and why? _________________

______________________________________________________________________________

______________________________________________________________________________

Do you take any OTC medications routinely (such pain relievers or allergy medicine)? If so, what and how often? ________________________________________________________________

Do you take prescription medications (prescribed by a licensed medical professional?) If so, what and how often? ________________________________________________________________________________________________

__________________________________________

 

Medical history:

Have you had any surgeries? If so, what and when? ____________________________________

______________________________________________________________________________

Have you received any diagnoses from licensed medical professionals? If so, what and when? ________________________________________________________________________

______________________________________________________________________________

 

Naturopathic history:

Have you ever been in consultation with a naturopath? If so, why? 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 bodywork/massages? __________________________________________

           

Please check all with which you are familiar:

  • Homeopathy

  • Bach Flowers/flower remedies

  • Probiotics

  • Aromatherapy

  • Muscle response testing

  • Herbals

  • Sports Nutrition

  • Enzymes

 

 

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 a medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, 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.

 

Signature _____________________________________________  Date ____________________

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