APPENDIX B

Client Intake Form

Client Name ____________________________ Date ___________________________

Client Information

Address _______________________________________________________________

City ___________________ State __________________ Zip _____________________

Phone (Home) ________________________ Work _____________________________

Cell ___________________________________________________________________

E-mail _________________________________________________________________

Date of Birth _________________________ Gender: M F

Employer__________________________ Occupation___________________________

Marital Status:    Single     Married     Partnership     Divorced     Separated        Widowed

Spouse/Partner Name ______________________# of Children____________________

Emergency Contact ______________________________________________________

Contact Phone:

Home _________________ Work __________________ C ell ____________________

Primary Health Care Provider

Name _________________________________________________________________

Address _______________________________________________________________

City/State/Zip ___________________________________________________________

Phone ______________________________ Fax _______________________________

I give my therapist permission to consult with my health care provider regarding my health and treatment.

Comments

Initials ________________________________ Date ___________________________ _

1. Current Health Information

Height ___________________ Weight _____________________

List Health Concerns

Primary ___________________________________________________________

__________________________________________________________________

__________________________________________________________________

  Mild          Moderate          Disabling          Constant          Intermittent

  Symptoms     w/activity

  Symptoms     w/activity

  Getting worse       getting better       no change

Treatment received _____________________________________________________

_____________________________________________________________________

Secondary ____________________________________________________________

_____________________________________________________________________

  Mild       Moderate       Disabling       Constant       Intermittent

  Symptoms     w/activity

  Symptoms     w/activity

    Getting worse       getting better       no change

Treatment received _____________________________________________________

_____________________________________________________________________

Have you ever received Energy Therapy before?

  Y          N    Frequency? __________________________

Have you ever received Manual Therapy before?

  Y          N    Frequency? __________________________

Have you ever received Psychotherapy before?

  Y          N    Frequency? __________________________

What kinds of practitioners (formal/informal) have you worked with around food/diet/nutrition (example: Dietician, Health Coach, or Nutritional Therapist)?

_____________________________________________________________________

_____________________________________________________________________

List all conditions currently monitored by a Health Care Provider.

_____________________________________________________________________

____________________________________________________________________ _

List Daily Activities

Work _______________________________________________________________

Work Hours and Schedule ______________________________________________

Do you now or have you ever worked the night shift?           Y           N

If so, please explain ___________________________________________________

If currently, what are your hours? _________________________________________

Home/Family _________________________________________________________

Social/Recreational ____________________________________________________

Circle the above activities affected by your condition.

  all of the above

Check other activities affected:

  sleep          washing          dressing          fitness

How do you reduce stress? _____________________________________________

Pain? ______________________________________________________________

What are your goals for receiving therapy? _________________________________

2. Health History

List & include dates & treatments. Add pages if necessary.

Surgeries _____________________________________________________________

_____________________________________________________________________

Accidents (physical-psychological) _________________________________________

_____________________________________________________________________

Major Illnesses ________________________________________________________

_____________________________________________________________________

Women

Last Pap _______________ First day of last menstrual period _________________

Marital/Partner History (Years Married ___________ Number of Children ________

Ages of Children _______________ Number of pregnancies __________________

Complications _______________________________________________________

Use of Contraceptive          Y          N

What type? _________________________________________________________

Abortions/Miscarriages? ______________________________________________ _

4. Family Medical History

Please give age, lists of any illness, or if deceased. If deceased, list cause of death and age of death.

Mother:

Father:

Siblings:

Mother’s parents:

Father’s parents:

5. Current Dietary Habits

Please list any specific diets that you are currently following, for example, vegan diet (no dairy, meat, fish or eggs), vegetarian, Atkins, paleo, DASH, raw, GAPS, etc: _____________________________________________________________________

_____________________________________________________________________

Eating Behaviors

Briefly describe your mealtime and snack patterns:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Food Allergies and Sensitivities

  Wheat allergy                Wheat sensitivity

  Dairy allergy                  Dairy sensitivity

Please list any other known or suspected food allergies and sensitivities: _________

Are there foods you could not give up? If so, which ones? _____________________

Current Food Preparation Methods

Who’s doing the shopping?          You          Family member          Friend          Other

Do you eat with people or alone          People          Alon e

Do you eat out?          Yes          No

If so, how often?          Once monthly          Twice monthly          Weekly          Daily

What kinds of places do you eat out? _____________________________________

Do you prepare your own food?          Yes          No

Do you enjoy cooking?          Yes          No

How do you feel about food preparation and cooking? __________________________

_____________________________________________________________________

How much time do you spend preparing food each day?

  Never          1 hour          2 hours          3 hours

Food Symptoms

Please circle any of the following food symptoms that you experience on a regular basis:

Stomachaches        Burping                 Itching

Sinus                       Flatulence             Flushing

Fatigue                    Bloating

6. Diet History

Were you breastfed, and if so, until what age?          Yes          No         Until age: _____________

Were you fed formula as a baby?                              Yes          No

Did you experience ear infections as a child?            Yes          No

Use of antibiotics as a child/adult?                             Yes          No

Please list any other childhood illnesses and the age at which they occurred: ___________________________________________________________________

_____________________________________________________________________

Please list any digestive complaints you recall having as a child (for example, stomach pains, diarrhea, constipation, gas, etc.) _________________________________________________________________

_____________________________________________________________________

Please list any other physical complaints you recall as a child (for example, fatigue, headaches, pain): ____________________________________________________

Acne as an adolescent?          None          Mild          Moderate          Severe

History of fasting?          Yes          No

Did you experience any eating disorders during adolescence?          Yes          N o

If so, please describe: _________________________________________________

____________________________________________________________________

____________________________________________________________________

Briefly describe your family’s eating habits and meal times (Did you eat as a family? Did you eat at the table or in front of the television? Did you fend for yourself? Were foods prepared from packages? Was there fighting at meal-time?): __________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

7. Medications (Current and Past Use)

In the table below, please list any medications, including pharmaceuticals and antibiotics that you are currently or have previously taken.

Medication	Prescribed For	Dosage	Frequency	Dates/Duration
E.g., Wellbutrin	Depression	100 mg	2/day	2010 – present

8. Use of Non-Pharmaceutical Substances

CURRENT	PAST	TIMES PER WEEK / COMMENTS
		tobacco __________________________________________
		alcohol/drugs ______________________________________
		coffee/soda _______________________________________
		other ____________________________________________

Are you a recovering alcoholic?                                      Yes                  No

History of drug or alcohol abuse?                                   Yes                  N o

Long term use of prescription/recreational drugs?          Yes                 No

If yes, how often and in what form? ____________________________________

Do you use Nutrasweet (aspartame)?                             Yes                 No

9. Use of Nutritional Supplements / Herbs / Minerals

In the table below, please list any supplements, including vitamins, minerals, herbs, amino acids, and hormones that you are currently or have previously taken.

Supplements	Manufacturer	Dosage	Frequency	Dates/Duration
E.g., Vitamin C	Biotics Research	500 mg	2/day	2012—4 months

10. Detoxification

If you are currently or have previously done any detoxification methods, please indicate which ones by filling in the table below. If you have done a detoxification method that is not listed in the table, write the name of it in the row marked “other.”

Method	How Often	When	Dates/Duration	Desired/Perceived Benefits
E.g., Skin Brushing	1–2 times / day	Before bathing	2013–presen t	Strengthen immunity
Skin Brushing
Coffee Enema
Liver Flush
Juice Fast
Colon Cleanser
Epsom Salt Bath Soak (magnesium sulfate)
Salt and Baking Soda Bath
Vinegar Bath
Sweats/ Saunas
Castor Oil Packs
Master Cleanse
Other

11. Pain / Discomfort

Mark areas of pain/discomfort:

Please describe the location and experience of pain:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Rate your stress level as of today

1 Low ____________________________________________________ 10 Hig h

12. Check all Current and Previous Conditions (please explain)

General

CURRENT	PAST	COMMENT
		headaches _______________________
		pain ____________________________
		sleep disturbances _________________
		fatigue __________________________
		infections in the ears _______________
		fever ___________________________
		sinus ___________________________
		other ___________________________

Skin Conditions

CURRENT	PAST	COMMENT
		rashes _________________________
		athelete’s foot, warts _____________
		other __________________________

Allergies

CURRENT	PAST	COMMENT
		scents, oils, lotions ______________
		detergents _____________________
		other _________________________

Muscles and Joints

CURRENT	PAST	COMMENT
		rheumatoid arthritis _____________
		osteoarthritis __________________
		scoliosis ______________________
		broken bones __________________
		spinal problems ________________
		disk problems _________________
		lupus ________________________
		TMJ, jaw pain _________________
		spasms, cramps ________________
		sprains, strains _________________
		tendonitis, bursitis ______________
		stiff or painful joints ____________
		weak or sore muscles ____________
		neck, shoulder, arm pain __________
		low back, hip, leg pain ___________
		other _________________________

Nervous System

CURRENT	PAST	COMMENT
		head injuries, concussions _________
		dizziness, ringing in the ears _______
		loss of memory, confusion _________
		numbness, tingling _______________
		sciatica, shooting pain ____________
		chronic pain ____________________
		depression ______________________
		other __________________________

Respiratory, Cardiovascular

CURRENT	PAST	COMMENT
		heart disease ____________________
		blood clots _____________________
		stroke _________________________
		lymphadema ____________________
		high, low blood pressure ___________
		irregular heart beat _______________
		poor circulation __________________
		swollen ankles ___________________
		varicose veins ___________________
		other __________________________
		pregnancy ______________________
		chest pain, shortness of breath ______
		asthma ________________________
		palpable heartbeat in abdomen _____

Digestive/Elimination System

CURRENT	PAST	COMMENT
		bowel dysfunction _______________
		gas, bloating ____________________
		bladder/kidney dysfunction ________
		abdominal pain __________________
		ulcers, colitis ____________________
		belching/gas within 1 hour after eating ____
		heartburn/acid reflux ______________
		bloating within 1 hour after eating ___
		bad breath (halitosis) _____________
		sweat has strong odor _____________
		feel like skipping breakfast _________
		feel better if you don’t eat __________
		sleepy after meals ________________
		stomach pains/cramps _____________
		diarrhea ________________________
		undigested food in stool ___________
		pain between shoulder blades _______
		stomach upset by greasy foods ______
		nausea _________________________
		light or clay colored stools _________
		gallbladder attacks _______________
		gallbladder removed ______________
		hemorrhoids or varicose veins ______
		chronic fatigue / fibromyalgia ______
		pulse speeds after eating ___________
		airborne allergies, hives ___________
		sinus congestion, “stuffy head” _____
		crave bread or noodles ____________
		alternating constipation/diarrhea ____
		crohn’s disease __________________
		asthma _________________________
		sinus infections __________________
		use over-the-counter pain medications ____
		anus itches _____________________
		history of antibiotic use ___________
		fungus or yeast infections _________
		irritable bowel/colitis ____________
		other _________________________

Endocrine System

CURRENT	PAST	COMMENT
		thyroid dysfunction _____________
		HIV/AIDS ____________________
		diabetes ______________________
		other ________________________

Reproductive System

CURRENT	PAST	COMMENT
		pregnancy ____________________
		reproductive problems __________
		painful, emotional menses _______
		fibrotic cysts __________________

Cancer/Tumors

CURRENT	PAST	COMMENT
		benign _______________________
		malignant ____________________ _

13. Meaning of Food

Please describe in a few sentences what food means to you. There may be both positive and negative associations. There is no right or wrong to this answer. For example, is food important to you? Are you preoccupied with it? Does it feel nourishing? Does food cause fear or discomfort?

__________________________________

__________________________________

__________________________________

__________________________________

14. Motivation for Nutritional Change

Identify 3 reasons to improve your diet:

1. __________________________________________

2. __________________________________________

3. __________________________________________

Identify 3 obstacles to improving your diet:

1. __________________________________________

2. __________________________________________

3. __________________________________________

Identify 3 goals to improve your diet:

3 month goal: ________________________________

6 month goal: ________________________________

12 month goal: _______________________________

Identify 3 goals to improving your food preparation:

3 month goal: ________________________________

6 month goal: ________________________________

12 month goal: _______________________________