Client intake form

Nutritional Profile and Client Intake Form

                                             Email: ______________________________

Name _______________________________________________ Age ____________ Date ________________

Phones (Home) _____________________ (Work) ______________________ (Cell) _____________________

Address __________________________________________________________________________________

Had any surgery? ______ (Describe) ___________________________________________________________

Medical traumas? ______ (Describe)    __________________________________________________________

Psychological traumas? ______ (Describe) _______________________________________________________

Taking any medication? (Also in the past) _______________________________________________________

Vaccination history _________________________________________________________________________

Dental history (Filling materials) ______________ (Teeth pulled) ___________ (Root Canals)______________

On birth control pill? __________

Nutritional supplement? ______ How long? ____________ (Describe) ________________________________

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Taking drugs? (Cocaine, H, marijuana, pills, etc.) _________________________________________________

Smoke? ______ (Quantity) __________________________ How long? ______________________________

Use alcohol? ______ (Quantity) __________________________ Past habit? ___________________________

Drink coffee? ______ (Quantity) ___________________ Milk? ________ (Quantity) ____________________

Like sweets? _______ In what form? ___________________________________________________________

Nervous? __________ Depressed? ___________ Under stress? ______________________________________

Eat beef? _______ (Frequency) _____________________ Pork? ________ (Frequency) __________________

Typical breakfast (Describe) __________________________________________________________________

Typical lunch (Describe) _____________________________________________________________________

Typical dinner (Describe) ____________________________________________________________________

Snacks? _______ When? ______________ (Describe) _____________________________________________

Estimated percentage of uncooked food daily? ____________________________________________________

How many glasses water daily? ________ Purified or tap? __________________________________________

Sleep well? _______ Usually how long? ________________________ Naps? ___________________________

Do you exercise? _______ How many times weekly? _____________ How long? _______________________

Is your job physical? ________________________________________________________________________

How often do your bowels eliminate? ___________________________________________________________

Any numbness of hands or feet? ________________________ Leg aches or cramps? _____________________

Been to a Doctor lately? ________________ Reason? ____________________________________ Diagnosis? __________________________________________________________________________________________

Other concerns: ____________________________________________________________________________

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On a scale of 1-10, 10 being the very best, how do you rate your energy level? __________________________

Briefly state why you have come to this session. __________________________________________________

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Any other information about your history you need to share. (Family, Job, Other social concerns, Hopes, Dreams, Goals) ____________________________________________________________________________

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