Intake Form Your Health Journey Starts Here Intake Form Step 1 of 13 7% FacebookThis field is for validation purposes and should be left unchanged.Indicative InformationFirst name(Required)Last name(Required)Mailing address(Required)City(Required)State(Required)Zip code(Required)Phone number(Required)Email address(Required) Body MeasurementsWhat is your age?What is your weight?What is your height?Select feet345678inchesSelect inches01234567891011What is your gender?(Required) Male Female Beverage Intake Please estimate how much you typically drink per day. One glass or cup = 8 oz. Alcohol is measured separately per week.Water(Required)1 glass = 8 oz. One standard water bottle = approximately 16–17 oz.Select AmountNone1-15 oz (less than 2 glasses)16-31 oz (about 2-4 glasses)32-47 oz (about 4-6 glasses)48-64 oz (about 6-8 glasses)65+ oz (more than 8 glasses)Coffee(Required)1 cup = 8 ozSelect AmountNone1 cup (8 oz)2 cups (16 oz)3 cups (24 oz)4+ cups (32 oz)Tea(Required)1 cup = 8 ozSelect AmountNone1 cup (8 oz)2 cups (16 oz)3 cups (24 oz)4+ cups (32 oz)Milk(Required)1 glass = 8 ozSelect AmountNone1 cup (8 oz)2 cups (16 oz)3 cups (24 oz)4+ cups (32 oz)Sugary drinks (including soda)(Required)Includes soda, sweet tea, lemonade, sports drinks, energy drinks, and other sweetened beverages. 1 glass = 8 ozSelect AmountNoneLess than 1 glass (1-7 oz)1 glass (8-15 oz)2-3 glasses (16 to 31 oz)4+ glasses (32+ oz)Other beverages(Required)Includes juice, smoothies, protein shakes, kombucha, and any other beverages not listed above. 1 glass = 8 ozSelect AmountNoneLess than 1 glass (1-7 oz)1 glass (8-15 oz)2-3 glasses (16 to 31 oz)4+ glasses (32+ oz)Alcohol Consumption(Required)Includes juice, smoothies, protein shakes, kombucha, and any other beverages not listed above. 1 glass = 8 ozSelect Weekly AmountNoneLess than 1 drink per week1-3 drinks per week4-7 drinks per week8-14 drinks per week15 or more drinks per week Your Eating Habits: Please tell us about your typical eating habits. Choose the option that best reflects your usual intake.In a typical week, how often do you eat the following?Fruit(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Vegetables(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Eggs(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Dairy(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Fermented foods (e.g., sauerkraut, pickles, kombucha)(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Fast food(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Chicken(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Fish(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Red meat(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Pork(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)Meat alternatives (e.g., beans, lentils, tofu)(Required)Select an optionNever (0 days)1-2 days per week3-4 days per week5-6 days per weekEvery day (7 days)What time do you eat your first meal of the day?(Required)Select a time10.00 AM11.00 AM12.00 AM1.00 PM2.00 PMWhat time do you eat your last meal of the day?(Required)Select a time6.00 PM7.00 PM8.00 PM9.00 PMWhat did your breakfast consist of?What is typically your largest meal of the day?(Required)SelectBreakfastLunchDinnerVariesDescribe a typical large meal.Additional InformationOver the last week, how many days did you consume artificial sweeteners?(Required)SelectNone (0 days)1 day2 days3 days4 days5 days6 daysEvery day (7 days)Over the last week, how many days did you consume artificial sweeteners?What foods do you crave?What foods do you dislike or choose to avoid, and why?Do any foods cause you physical discomfort (e.g., bloating, gas, stomach upset, headache)? No Yes Not sure If yes, please list the foods and the symptoms you experience ExerciseDo you participate in activity where you break a sweat?(Required) Yes No How often do you participant in this activity?What is this activity?Do you look forward to participating in it?How do you feel when you’re finished participating in it? SleepWhat time do you get into bed?On average, about what time do you fall asleep?On average, for how many hours a night do you sleep?Do you often wake up in the middle of the night? Yes No If so, why and at approximately what time(s)?When you wake in the morning, do you feel rested? Yes No When you wake in the morning, do you experience pain? Yes No If so, where? How intense?Upon movement, does the pain go away? Potty TimeDo you have daily bowel movements? Yes No This field is hidden when viewing the formWhen you wake in the morning, do you feel rested? Yes No How many bowel movements per day do you have?Describe the frequency of your bowel movements? Please continue through the remaining sections of the intake form. Once all questions are completed and the intake is signed and dated, you will be directed to a Bristol Stool Chart to select the option that best matches your typical bowel movement and complete the intake process.FemaleAre you post-menopausal? Yes No At what age did you enter menopause?(Required)What were the characteristics of your menopausal experience?(Required)Do you currently use Hormone Replacement Therapy (HRT)?(Required)Are you now, or in the near future, planning to become pregnant? Yes No This field is hidden when viewing the formIf yes, how many bowel movements do you have per day?This field is hidden when viewing the formIf no, please describe your elimination pattern.Do you currently use hormonally-based contraception? Yes No Is your menstrual cycle regular? Yes No Is your irregular menstrual cycle longer than or shorter than 28 days?LongerShorterIs your flow longer or shorter than 5 days?LongerShorterDo you have cramps or clottingCrampsClottingNoneWould you describe the color of your menses as bright red, dark purple, or brown?Bright RedDark PurpleBrownDo you experience PMS, cyclical headaches, or cravings?PMSCyclical HeadachesCravingsNone Supplements & MedicationDo you take any supplements?(Required) Yes No Describe what supplement(s), how often, and what for?(Required)Do you take any over-the-counter medications routinely (such pain reliever or allergy medicine)?(Required) Yes No This field is hidden when viewing the formIs your irregular menstrual cycle longer than or shorter than 28 days?LongerShorterThis field is hidden when viewing the formIs your flow longer or shorter than 5 days?LongerShorterWhat over-the-counter medications do you take and how often?(Required)Do you take prescription medications (prescribed by a licensed medical professional)?(Required) Yes No This field is hidden when viewing the formDo you have cramps or clottingCrampsClottingNoneThis field is hidden when viewing the formWould you describe the color of your menses as bright red, dark purple, or brown?Bright RedDark PurpleBrownWhat prescription medication(s) do you take and how often?(Required) Medical HistoryHave you had any surgeries?(Required) Yes No This field is hidden when viewing the formDo you take any supplements? Yes No This field is hidden when viewing the formIf so, what, how often and why?This field is hidden when viewing the formDo you take any over-the-counter medications routinely (such pain reliever or allergy medicine)? Yes No This field is hidden when viewing the formIf so, what and how often?This field is hidden when viewing the formDo you take prescription medications (prescribed by a licensed medical professional)? Yes No This field is hidden when viewing the formIf so, what and how often?This field is hidden when viewing the formDo you experience PMS, cyclical headaches, or cravings?PMSCyclical HeadachesCravingsDescribe the surgery or surgeries that you have had and approximately when they were.(Required)Have you received any diagnoses from licensed medical professionals? Yes No This field is hidden when viewing the formDo you take any supplements? Yes No This field is hidden when viewing the formIf so, what, how often and why?Describe the diagnoses that you have received? Naturopathic HistoryHave you previously had a consultation with a naturopath? Yes No This field is hidden when viewing the formDo you take any over-the-counter medications routinely (such pain reliever or allergy medicine)? Yes No This field is hidden when viewing the formIf so, what and how often?This field is hidden when viewing the formDo you take prescription medications (prescribed by a licensed medical professional)? Yes No This field is hidden when viewing the formIf so, what and how often?This field is hidden when viewing the formHave you had any surgeries? Yes No What was the consultation for and how long ago was it?(Required)What was suggested from the consultation?(Required)Did you experience a good outcome?(Required)What did you like about it?(Required)What wasn’t as successful for you?(Required)Do you have regular adjustments performed by a chiropractor? Yes No Do you have regular body work/massages? Yes No Check all with which you are familiar: Homeopathy Homeopathy Bach Flowers Bach Flowers Probiotics Probiotics Aromatherapy Aromatherapy Muscle Response Testing Muscle Response Testing Herbals Herbals Sports nutrition Sports nutrition Enzymes Enzymes ConsentBy checking the box below, you understand that you are here to learn about nutrition and better health practices, that will be offered as information about food supplements and herbs as a guide to general good health. You fully understand that those who counsel you are not medical doctors and you are not here for medical diagnostic purpose or treatment procedures. You are not on this visit, or any subsequent visit, as 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.SignatureYour NameYour NameYour NameYour NameThis field is hidden when viewing the formNameDate Potty Time EmailThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formSelect Bristol Stool Chart Number1. Severe Constipation - Severe Dehydration2. Mild Constipation - Mild Dehydration3. Near Perfect4. Perfect5. Lacking Fiber6. Mild Diarrhea7. Severe Diarrhea - Bowel Infiammation/IllnessSelect the image that most closely matches your typical bowel movement. 1. Severe Constipation - Severe Dehydration 2. Mild Constipation - Mild Dehydration 3. Near Perfect 4. Perfect 5. Lacking Fiber 6. Mild Diarrhea 7. Severe Diarrhea - Bowel Infiammation/Illness First Name(Required)Last Name(Required)Phone(Required)
