Client Intake FormThank you for filling out this form and providing details of your health, goals, and medical history. CLIENT INFORMATION Name * First Name Last Name Email * Referred By * What's prompting you to have a Functional Nutrition Assessment? 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? * Have you experienced any success with these approaches? * What other health practitioners are you currently seeing? * Have you had any recent surgical procedures? If so, please share details. At any time in your life, have you taken antibiotics for an extended period of time? Please elaborate. * List all vitamins, herbs and nutritional supplements you are now taking. * Have any other family members had similar problems (describe)? * HISTORY Have you lived or traveled outside of the United States? If so, when and where?: Have you or your family recently experienced any major life changes? * Have you experienced any major losses in life? If so, please comment: * Have you had to take any extended time off of work in the last year? If so, how long? * NUTRITIONAL STATUS Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom. * Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? * Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? * Are there foods that you crave? * Describe your diet at the onset of your health concerns. * Do you have any known food allergies or sensitivities? * Do you consume anyy of the following foods * Soda / Diet Soda Alcohol Fast Food Gluten Dairy Coffee Refined Sugar Are you currently following any specialty diet? * Autoimmune Paleo (AIP) SCD/GAPS Dairy-Free Vegetarian Vegan Raw Paleo Gluten-Free Sugar-Free Other None What percentage of your meals are home-cooked? Is there anything else you'd like to share 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: Soft & well-formed Often float Difficult to pass Diarrhea Thin, long or narrow Small and hard Loose but not watery Alternating between hard and loose Bowel Movement Color: Medium brown Very dark or black Greenish Blood is visible Variable Yellow, light brown Chalky colored Greasy, shiny Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc. Have you ever had food poisoning? If yes, please describe in detail, including 1) Where were you 2) What did you treat it with and 3) If you feel like you fully recovered from it MEDICAL STATUS Please identify any current or past conditions: Irritable Bowel Syndrome (IBS) Crohn’s Ulcertative Colitis Gastritis GERD (reflux or heartburn) Celiac Disease SIBO Gut infections Dysbiosis Leaky Gut Food allergies, intolerances or reactions Gallstones Known absorption or assimilation issues Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past conditions: Heart attack Heart disease Stroke Elevated cholesteral Arrhythmia (irregular heartbeat) Hypertension (high blood pressure) Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past conditions: Type 1 Diabetes Type 2 Diabetes Hypoglycemia Insulin Resistance or Pre- Diabetes Hypothyroidism (low thyroid) Hyperthyroidism (overactive thyroid) Hashimoto’s (autoimmune hypothyroid) Grave’s Disease (autoimmune hyperthyroid) Polycystic Ovarian Syndrome (PCOS) Infertility Weight loss / gain / frequent fluctuations Eating disorder Menopause difficulties Hair loss Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Lung cancer Breast cancer Skin cancer Colon cancer Ovarian cancer Prostate cancer Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Kidney stones Gout Frequent urinary tract infections Frequent yeast infections Interstitial Cystitis Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Osteoarthritis Fibromyalgia Chronic pain Frequent sore muscles or joints Others Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Chronic Fatigue Syndrome Rheumatoid Arthritis Lupus SLE Psoriasis Food allergies Poor immune function (frequent infections) Environmental allergies Multiple chemical sensitivities Hepatitis Lyme Chronic infections Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Asthma Chronic Sinusitis Bronchitis Pneumonia Sleep Apnea Frequent or recurrent Colds/Flus Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Eczema Psoriasis Dermatitis Hives Rash, undiagnosed Acne Other Please briefly describe your symptoms, chosen treatment(s), and dates. Please identify any current or past diagnosis: Depression Anxiety Bipolar disorder Headaches Migraines ADD/ADHD Mild cognitive impairment Memory problems Parkinson’s Disease Multiple Sclerosis Seizures Other Please briefly describe your symptoms, chosen treatment(s), and dates. Short term memory impairment: Yes No Sometimes Shortened focus of attention and ability to concentrate: Yes No Sometimes Coordination and balance problems: Yes No Sometimes Problems with lack of inhibition: Yes No Sometimes Poor organization abilities: Yes No Sometimes Problems with time management (late or forget appts): Yes No Sometimes Mood instability: Yes No Sometimes Difficulty understanding speech and word finding: Yes No Sometimes Brain fog, brain fatigue: Yes No Sometimes Lower effectiveness at work, home or school: Yes No Sometimes Judgment problems like leaving the stove on, etc: Yes No Sometimes Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)? Do odors affect you? Are you or have you been exposed to second-hand smoke? How long since you last visited the dentist? What was the reason for that visit? In the past 12 months has a dentist or hygienist talked to you about your oral health, blood sugar or other health concerns? (Explain.) What is your current oral and dental regimen? (Please note whether this regimen is once or twice daily or occasionally). Do you have any mercury amalgams? (If no, were they removed? If so, how?) Do you have any concerns about your oral or dental health? Is there anything else about your current oral or dental health or health history that you’d like us to know? Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time. Have you used alcohol, drugs, meds, tobacco or caffeine? Do you still? How do you handle stress? Are you satisfied with your sleep? Do you stay awake all day without dozing? Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.? Do you fall asleep in less than 30 minutes? Do you sleep between 6 and 8 hours per night? How old were you when you first got your period? How are/were your menstral cycle? Do/did you have PMS? Painful periods? If so, explain In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability? Have you experienced any yeast infections or urinary tract infections? Are they regular? Have you/do you still take birth control pills: If so, please list length of time and type. Have you had any problems with conception or pregnancy? Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here. How are your moods in general? Do you experience more anxiety, depression or anger than you would like? On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy. At what point in your life did you feel best? Why? Who in you family or on your health care team will be most supportive of you making dietary change? 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? Though it may seem odd, please consider why you might want to achieve that for yourself: Thank you!
