CLIENT INFORMATION
Name: *
Phone (home/ cell):
E-Mail: *
How did you hear about me?
STATISTICS
Age:
Birth Date:
Gender:
Height/Weight:
Occupation:
Family/Children:
Exercise/Recreation:
Have you lived or traveled outside of North America? If so, when and where?
Have you or your family recently experienced any major life changes?
Have you experienced any major losses in life?
Anything from your history that you consider relevant to our conversation?
HISTORY HEALTH CONCERNS
What are your main health concerns?
When did you first experience these concerns?
How have you dealt with these concerns in the past? (Doctors, self care, etc.)
What other health practitioners are you currently seeing?
Please list any surgeries you have had in the past:
What is your history with antibiotic use?
List any medications/birth control pills/etc. you are currently taking:
List all nutritional supplements you are taking (vitamins/mineral/herbs/probiotics, etc):
Have any other family members had similar problems/concerns as to what you are experiencing?
NUTRITIONAL STATUS
If there are foods you avoid because of the way they make you feel, please name the food and symptom:
Do you have any symptoms immediately after eating like bloating, gas, sneezing, hives? Please explain:
Are you aware of any delayed symptoms after eating certain foods, such as fatigue, muscle aches, sinus congestion, etc? Please explain.
Are there foods you crave?
Describe your diet at the onset of your health concerns:
Do you have any known food allergies/sensitivities?
Which of the following foods do you consume regularly?
Soda
Diet soda
Refined sugar
Alcohol
Fast food
Coffee
Gluten (wheat or rye or barley)
Dairy (milk or cheese or yogurt)
If other, please describe.
Are you currently on a special diet?
SCD/GAPS
Paleo
Autoimmune paleo (AIP)
Blood type
Raw
Vegan
Vegetarian
Gluten-free
Refined sugar-free
Dairy restricted or dairy free
Is there anything else you would like to describe about your current diet, history or relationship to food?
INTESTINAL STATUS
Bowel Movement Frequency: 1-3 times per day More than 3 times per day Not regularly every day
Bowel Movement Consistency:
Diarrhea
Constipation
Food in stool
Greasy or shiny
Do you experience intestinal gas? Excessive, occasional? Pain?
MEDICAL STATUS
Please check any of the following conditions that apply and briefly describe your symptoms, treatments, date of diagnosis:
Cancer
Heart Disease
IBS/Crohn’s
Diabetes
Asthma
Allergies
Anemia
Kidney Disease
Thyroid Disease
Depression/Anxiety
High Cholesterol
High Blood Pressure
Chronic Yeast Infections
If other, please list.
LIFESTYLE
Sources of stress:
How do you handle stress?
How do you relax? (What brings you JOY?)
SLEEP HISTORY
Describe your typical sleep experience/duration:
Do you stay awake all day without dozing?
Do you wake feeling rested?
MENTAL HEALTH STATUS
Describe your moods in general? Do you experience more anxiety, depression or anger than you would like?
Do you experience brain fog/memory problems/migraines/etc?
Describe your energy level during the day (1=low, 10=high): 1 2 3 4 5 6 7 8 9 10
At what point in your life have you felt the best?
OTHER
Please describe any other information you think would be useful in helping to address your health concern(s):
What are your health goals and aspirations?
Do you have people in your life who will be supportive of you making health and lifestyle changes to improve your quality of life? Please explain:
