New Client Intake Form

Name

First

Last

Birth date; Age

Email address

Mobile Phone

Address

Thank you for contacting me! How did you find me?

Occupation

How would you describe your general health?

What is your height and weight?

Do you currently, or have you in past, smoked tobacco? How much per day?

Do you exercise on a regular basis? What sort of physical activity do you enjoy?

I take the functional nutrition approach toward understanding the root cause of a client's health issues. This involves dietary modification and the use of targeted therapeutic supplements to treat these issues. Does this sound like the approach you are looking for?

What is your main nutritional concern at this time? How can I help you?

Have these issues been improving or getting worse over the past few months?

Do you have any medical, developmental, neurological or psychiatric conditions that you'd like me to be aware of?

The gut microbiome (microorganisms normally inhabiting the GI tract) are central to many health and mental issues. Do you have any GI problems or issues, including constipation or loose stool? Please explain. We will explore these at our initial consultation.

Are you taking any medications for any of these issues? Please list.

Are you taking any dietary supplements? Please list

How would you describe your diet and eating habits? Please be as descriptive and detailed as possible.

How motivated would you say you are in making changes in your diet and eating habits? Have you tried to make changes in your diet in the past? How successful were you?

What are your expectations in working with me? What are your goals?

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New Client Intake Form

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