Name
Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
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Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
ZipCode
Date Of Birth
Phone:
Email
Complaint
NUTRITIONAL DATA: How many ounces of water per day?
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What kind?
Alkaline
Distilled
Filtered
Ionized
Reverse Osmosis
Spring
Tap
What other beverages and how much?
If you have breakfast, what do you normally eat?
Do you use artificial sweeteners?
If yes, which ones, how often, and in what?
Other
What are your favorite foods?
What foods do you dislike the most and why?
TIMING: What is the first thing you do when you get up in the morning?
What time do you eat your first meal?
Time of last meal?
Which meal is your largest of the day?
Breakfast
Lunch
Dinner
Brunch
Snack Times
Describe a typical largest meal:
Smoking
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Coffee
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Soda pop
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Alcoholic Beverages
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Sugar
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Fruit
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Vegetables
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Eggs
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Dairy
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Fermented food
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Fast food
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Chicken
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Fish
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Red meat
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Pork
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Meat alternatives
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MOVEMENT: Do you exercise/move/participate in fun, sweaty activity?
If yes, what and how often?
Do you look forward to it?
How do you feel when you are finished?
:SLEEP: What time do you go to bed?
How long do you sleep?
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If yes, why and at what times?
Do you feel rested when you wake up for the day?
Do you have pain when you first wake up?
If yes, where?
Does it go away upon moving?
ELIMINATIONS: Do you have daily bowel eliminations?
If yes, how many per day?
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If no, please describe your pattern.
FEMALES: Are you post-menopausal?
If yes, at what age did you enter menopause?
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What were the characteristics of your menopausal experience?
Do you use Hormone Replacement or Hormonally-based Contraception?
Are you planning to become pregnant now or in the near future?
Is your menstruation cycle regular?
Is your flow longer or shorter than 5 days?
Do you have cramps or clotting?
What color is your menses?
Bright red
Dark purple
Brown
Do you experience PMS, cyclical headaches or cravings?
SUPPLEMENTS/MEDICATIONS: Do you take any supplements?
If yes, what, how often and why?
Do you take OTC medications regularly (such as pain or allergy medicines)?
If yes, what and how often?
Do you take prescription medications (prescribed by a licensed medical professional)?
If yes, what and how often?
MEDICAL HISTORY: Have you had any surgeries?
If yes, what and when?
Have you received licensed medical professional diagnoses?
If yes, what and when?
NATUROPATHIC HISTORY: Have you ever been in consultation with a naturopath?
If yes, what and when?
How long ago?
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Did you experience a good outcome?
What was suggested?
What did you like about it?
What was not as successful for you?
Do you have regular adjustments with a chiropractor?
Do you have regular body work or massages?
Agreement Terms
I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements, herbs, exercises, and lifestyle alterations or maintenance as a guide to general good health. I fully understand that those who counsel me are NOT medical doctors, and I am not here for medical diagnostic purposes, or medical treatment procedures. I am free to apply the information, guidance, and products received from this practice and its personnel to my benefit or choose otherwise. I am not on this visit, or any subsequent visit, an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters, exercises, or lifestyle alterations intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies or medications for a disease of any type.
I attest that I have answered any and all questions to the best of my ability in all honesty for review and will not hold liable any and all parties associated with the practice listed on this form or its affiliates for outcomes resulting in contrast or adversity due to the omission or incorrect answers to said questions presented to me on this form. The answers to these questions presented to me and any information given to me by this practice and its personnel during my initial consultation, standard appointments, follow-up appointments, scheduled sessions, or approved meetings, be it in person or virtual, will remain under the doctor to client privilege relationship thus completely confidential between parties and will not be shared with any individual that is not duly authorized by the practice and its personnel and myself.
You have reviewed and agreed with the terms of the form. By checking this agreement to terms box and typing your name on the Signature line below, you are signing this agreement electronically. You agree that your typed signature is the legal equivalent of your physical signature on this form. By checking the agreement to terms box and typing your name on the Signature line you consent that you are authorized to act on behalf of yourself or the person to which you are legal guardian to the terms outlined on this form and you consent, on behalf of yourself or the person to which you are legal guardian, to be legally bound by the agreement and all its terms and conditions.
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