Client Intake — Holistic Care Coaching!

Comprehensive Client Intake Form

Functional Nutrition Health History Intake Form

Name:

First Name

Last Name

Date:

YYYY

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address:

Phone Day:

(###)

###

####

Phone Evening:

(###)

###

####

Age:

Birth Date:

Height:

Weight:

Referred By:

1. Have you lived or traveled outside of the United States? If so, when and where?

2. Have you or your family recently experienced any major life changes? If so, please comment.

3. Have you experienced any major losses in life? If so, please comment.

4. How much time have you had to take off from work, school, or life, due to illness, in the last year?

5. What are your main health concerns? Describe in detail, including the severity of the symptoms.

6. When did you first experience these concerns?

7. How have you dealt with these concerns in the past?

8. Have you experienced any success with these approaches?

9. What other health practitioners are you currently seeing? List name, specialty.

10. Please list the date and description of any surgical procedures you have had. Have you had your gallbladder removed?

11. How often have you taken antibiotics in the last ten years? Why were you prescribed antibiotics?

12. List any medicine you are currently taking.

13. List all vitamins, minerals, herbs, and nutritional supplements you are currently taking. Please list the brand names as well.

14. Have any other family members had similar problems, if so, please describe?

15. Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom.

16. Do you have symptoms immediately after eating such as bloating, gas, sneezing, or hives? If so, please explain.

17. Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain.

18. Are there foods that you crave? If so, please explain.

19. Describe your diet at the onset of your health concerns.

20. Do you have any known food allergies or food sensitivities?

21. Which of the following foods do you consume regularly? □ soda □ diet soda □ refined sugar □ alcohol □ fast food □ gluten (wheat, rye, barley) □ dairy (milk, cheese, yogurt) □ coffee. Please list below.

22. Are you currently on a special diet? □ ovo-lacto □ diabetic □ dairy restricted or dairy-free □ vegetarian □ vegan □ paleo □ blood type □ raw □ refined sugar-free □ gluten-free

23. What percentage of your meals are home-cooked, □ 10 □ 20 □ 30 □ 40 □ 50 □ 60 □ 70 □ 80 □ 90 □ 100 percent?

24. Is there anything else we should know about your current diet, history, or relationship to food?

25. Don't be shy here. Bowel Movement Frequency □ 1–3 times per day □ more than 3 times per day □ not regularly every day.

26. 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.

27. Bowel Movement Color □ medium brown □ very dark or black □ greenish □ blood is visible □ variable □ yellow, light brown □ chalky colored □ greasy, shiny

28. Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:

29. Have you ever had food poisoning? If yes, please describe in detail, including where you were, what did you treat it with, and if you feel like you fully recovered from it.

30. Please list in form block any of the following conditions that apply to your history and briefly describe your symptoms and chosen treatment, and dates. □ Cancer □ Heart Disease □ Hepatitis □ Diabetes □ High Blood Pressure □ High Cholesterol □ Kidney Disease □ Thyroid Disease □ Depression □ Asthma □ Allergies □ Anemia □ Chronic Yeast Infections □ Other

31. Have you been exposed to any chemicals or toxic metals such as, lead, mercury, arsenic, or aluminum?

32. Do odors affect you?

33. Do you have mercury amalgam fillings?

34. 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.

35. Have you used or abused alcohol, drugs, medications, tobacco, or caffeine? Do you still?

36. How do you handle stress?

37. Are you satisfied with your sleep?

38. Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?

39. On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.

40. Do you stay awake all day without dozing?

41. When was your last vaccine of any kind?

This form was adapted from Replenish PDX-Andrea Nakayama.