Holistic Nutritional Consultant Initial Intake Form

Name*

First Last

Today's Date*

Age

Weight

Height

Sex

Relationship Status

Please answer all of the following questions.

What is your purpose in seeking nutritional guidance?

What are your main health concerns/complaints? Please list in priority.

Have you experienced any major physical/emotional trauma in the past five years?

What level of stress do you feel you are experiencing at this time?

Please quantify on a scale of 1 (Low) to 10 (high)

What areas of your life feel the most stressful?

How does your stress manifest itself?

Do you use any coping mechanisms?

What do you do for exercise? (Indicate type, frequency, time of day and duration)

How would you describe your energy levels?

Please quantify on a scale of 1 (Low) to 10 (high)

Do you experience any lulls or highs in your energy levels throughout the day? If so, at what time of day?

How many hours on average do you sleep daily? (include naps)

What time do you go to sleep?

Awaken?

Do you have trouble falling asleep? Staying asleep?

Do you awaken feeling rested?

Yes

No

Do you snore?

Yes

No

What is your occupation?

How many hours each day/week do you work?

Do you enjoy your work?

Yes

No

Sometimes

At what times do you start and end work?

Do you work shifts? Regular schedule?

Have you changed employment within the last 12 months?

Yes

No

What areas of your life feel the most stressful?

Do you smoke tobacco?

Yes

No

If yes, in what form, how much and for how long?

If no, does anyone in your household or workplace smoke tobacco?

Yes

No

Do you smoke marijuana?

Yes

No

If yes, how much and for how long?

Do you use recreational drugs?

Yes

No

If yes, how often and what type?

Have you ever been treated for drug and/or alcohol dependency?

Yes

No

If yes, which have you been treated for?

How long ago?

How do you feel about your body image?

Do you wish to

Gain weight

Lose weight

How much?

When do you wish to reach your goal weight?

What is your main motivation to change your weight?

How many hours do you spend daily, on average, driving?

How many hours do you spend daily, on average, watching television?

How many hours do you spend daily, on average, reading In front of a computer?

Which type of body care and household products do you use?

Conventional

Natural

What are your interests and hobbies?

Do you vacation regularly?

Yes

No

When was your last vacation?

Do you participate in any spiritual discipline (church, religious group, meditation, etc.)?

Yes

No

Explain more

Hereditary Diseases.

Allergies

Alcoholism

Arthritis

Alzheimer’s

Asthma

Autoimmune disease

Autoimmune disease type

Cancer

Cancer type

Cardiovascular disease

Cardiovascular disease type

Cystic Fibrosis

Diabetes

Drug Use

Heart Disease

Hemochromatosis

Iron-binding protein, causing liver damage

Huntington’s Disease

Degenerative Brain Disease

Hypertension

Intestinal disease

Intestinal disease type

Kidney Dysfunction

Liver/Gallbladder disease

Liver/Gallbladder disease type

Mental health disorder

Mental health disorder type

Obesity

Parkinson’s disease

Skin Conditions

Type 1 Diabetes

Type 2 Diabetes

Other

Explain other

Other

Explain other

Other

Explain other

Have you experienced fungal infections (e.g. jock itch, athlete’s foot)?

Yes

No

N/A

If yes, please describe

Have you experienced a decline in sexual interest?

Yes

No

N/A

If yes, please describe

Have you had kidney or gallstones?

Yes

No

N/A

If yes, please describe

Have you experienced any prostate problems (e.g. frequent urination, discomfort during urination)?

Yes

No

N/A

If yes, please describe

Please complete this section, identifying how often the following symptoms occur for you.

Please complete this section, identifying how often the following occur for you.

	N/A	Mild/Rarely	Moderate/Regular	Severe/Often
General fatigue or weakness
Difficulty losing weight
Frequent illness/infections
High stress lifestyle
Smoking
Drinking for than 2 cups of coffee/day
Bad breath and/or body odour
Constipation
Bags under eyes
Crave sugars, bread, alcohol
Difficulty digesting certain foods
Have used antibiotics in past 10 years
Allergies
Poor concentration or memory
Belching or burping after meals
Skin/complexion problems
Frequent consumption of red meat
Regular use of dairy products
Heavy alcohol consumption
Exposure to toxins/chemicals
Frequent mood swings
Depressed and/or irritable
Brittle fingernails
Dry, brittle hair, split ends
High fat, high cholesterol diet
Nervousness/anxiety/tension/worry
Insomnia/restless sleep
Low fiber diet
Muscle cramps
Sleepy when sitting up
Female: menstrual cramps
Bronchitis/asthma/pneumonia/emphysema
Cellulite
Cold hands and feet
Varicose veins
Feeling out of control
Food/chemical sensitivities
Frequent yeast/fungal problems
Bones break easily, osteoporosis
Too little exercise
Excessive mucous
Short of breath climbing stairs
Chest pains
Very rapid or slow heart beat
Painful, hard or thin bowel movements
Alternating constipation/diarrhea
Recurrent bladder infections
Female: Menopause, hot flashes
Female: PMS
Difficult urination
Swollen glands, puffy throat
Lower abdominal pain
Frequent need to urinate
Joint pain
Sinus inflammation/discharge
Arthritis
Sudden weight gain/loss
Headaches/Migraines
Female: Taking birth control pills
Lower back pain
Dry, flaky skin
Drink less than 6 glasses of fluid/day
Water retention
Low sex drive
Feeling heavy/bloated after meals
Chronic cough

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment, or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily

Date*

Signature*

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Thank you for your cooperation. All information contained on this form will be kept strictly confidential.

Holistic Nutritional Consultant Initial Intake Form

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