Health Intake Form Full Name * Address * Email * Phone Date of Birth Place of Birth Height Current Weight Would you like your weight to be different? If so, what would your ideal weight be? Relationship status? Children? Pets? Occupation? How many hours do you work per week? Please list your main health concerns. Include as much detail as you can: Please list all symptoms you are currently experiencing. When did symptoms begin? Any other health concerns and/or goals? Please list all supplements and medications you are currently taking. Include dosages and brands: Please list all diagnoses that you have received: Have you had any hospitalizations, surgeries or injuries? Allergies or sensitivities? Please explain: Do you sleep well? How many hours do you typically sleep? Do you wake up at night? If so, why? Do you experience pain anywhere in your body? If so, where? How is your digestion? Any constipation, diarrhea, gas or bloating? Do you follow any specific nutrition plan such as paleo, vegan, plant-based? If so, please describe: Please describe a typical day and/or week of eating: What percentage of your food is prepared at home? Do you cook? Do you crave sugar, coffee, cigarettes or have any addictions? What is the most important thing you would like to change about your diet? Do you have a juicer or high-powered blender? Will family and friends be supportive of your desire to make food and lifestyle changes? What roles do movement and exercise play in your life? At which point in your life did you feel your best? What is your ancestry? How is/was the health of your mother? How is/was the health of your father? Are your periods regular? How many days is your flow? How frequent? Painful or symptomatic? Have you reached or are you approaching menopause? Please explain: Birth control history? Do you own any Medical Medium books? If so, which ones? Are you currently working with any health practitioners or therapies? Any other concerns or issues you would like to address? Thank you! I look forward to being in touch soon.
