Holistic Nutritional Consultant Initial Intake Form

Welcome! An accurate health history is important to ensure that it is safe for you to receive a treatment. If your health status changes in the future, please let us know. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information.

"*" indicates required fields

1Basic Info
2Medical History
3Family History
6Dietary Habits
7Body-Mind Connection
9Client Statement
YYYY dash MM dash DD
Please answer all of the following questions.
Please quantify on a scale of 1 (Low) to 10 (high)
Please quantify on a scale of 1 (Low) to 10 (high)
Do you awaken feeling rested?
Do you snore?
Do you enjoy your work?
Have you changed employment within the last 12 months?
Do you smoke tobacco?
If no, does anyone in your household or workplace smoke tobacco?
Do you smoke marijuana?
Do you use recreational drugs?
Have you ever been treated for drug and/or alcohol dependency?
Do you wish to
Which type of body care and household products do you use?
Do you vacation regularly?
Do you participate in any spiritual discipline (church, religious group, meditation, etc.)?