Intake Form – Dynamic Life Nutrition

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Intake Form

Nutrition Client Intake Form

First Name

Last Name

Birthdate

Age

Address

Street Address

Apt, Suite, Bldg. (optional)

City

State

Zip Code

Country

Phone Number

Email Address

Heritage

Principal Language

Birth Weight (if known)

Birth Order

Gender

Male

Female

Transgender M to F

Transgender F to M

Medical Status

1. Please identify any current or past conditions and add a date for when the condition appeared. In the space below each list, please briefly describe your symptoms, chosen treatment(s), and dates.

Gastrointestinal

Past Conditions (may select more than one)

Current Conditions (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Cardiovascular

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Hormones/Metabolic

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Cancer

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Genetil and Urinary Systems

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Musculoskeletal/Pain

Multiselect

Multiselect

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Immune/Inflammatory

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Respiratory Conditions

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Skin Conditions

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Neurologic/Mood

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

Miscellaneous

Past (may select more than one)

Current (may select more than one)

Date Diagnosed

Date Diagnosed

Please briefly describe your symptoms, chosen treatment(s) and dates:

2. Please check frequency of the following:

Short term memory impairment

Coordination and balance problems

Shortened focus of attention and ability to concentrate

Problems with lack of inhibition

Lower effectiveness at work, home, or school

Short term memory impairment

Yes

No

Poor organization abilities

Problems with time management (late or forget appts)

Mood instability

Difficulty understanding speech and word finding

Brain fog, brain fatigue

Judgment problems like leaving the stove on, etc.

Stressful Life Events

Studies show that past and continued traumas play a significant role in health and health outcomes. Our understanding of your history helps us to best support you throughout this process and moving forward.

3. Have you experienced one or more of these stressful life events or traumas in your life?

Death of a family member, romantic partner or very close friend because of accident, homicide, or suicide

Yes

No

Emotional neglect or abuse such as ridicule, bullying, put downs, being ignored or told you were no good by a family member or romantic partner

Yes

No

Life-threatening accident or situation (military combat or lived in a war zone)

Yes

No

Physical force or weapon threatened or used against you in a robbery or mugging

Yes

No

Sexual or physical abuse by a family member, romantic partner, stranger, or someone else

Yes

No

Discrimination

Yes

No

Life-threatening illness

Yes

No

Witness the murder, serious injury, or assault of another person

Yes

No

4. Is there anything else that you would like to share about these stressful life events or traumas?

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? Doctors? Self-care? Other?

8. Have you experienced any success with these approaches? Please explain.

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

10. Please list the date and description of any surgical procedures you have had (including breast reduction or augmentation, gall bladder removal, and any office procedures).

11. How much time have you had to take off from work or school for health related reasons in the last year? (Add details if you can)

12. How often did you take antibiotics in infancy/childhood?

13. How often did you take antibiotics as a teen?

14. How often have you taken antibiotics as an adult?

15. List any medications you are currently taking, including dosage.

16. List all vitamins, minerals, herbs, and nutritional supplements you are now taking.

Nutritional Status

17.Which of the following foods do you consume regularly?

Soda

Diet soda

Refined Sugar

Alcohol

Gluten (wheat, rye, barley

Fast food

Dairy (milk, cheese, yogurt)

Coffee

18. Are you currently on a special diet?

Autoimmune Paleo (AIP)

SCD/GAPS

Dairy restricted or dairy-free

Vegetarian

Vegan

Paleo

Blood Type

Raw

Gluten-free

Intermittent Fasting

Other

19. What percentage of your meals are home cooked?

<25

25-50

50-75

75-100

20. Are there any foods that you avoid because of the way they make you feel? Please name any foods and symptoms from each.

21. Do you have symptoms immediately after eating like bloating, gas, sneezing, or hives? Do you have any known food allergies or sensitivities? If so, please list them.

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

23. Are there foods that you crave? Please list them.

25. Do you have any known food allergies or sensitivities? Please list them.

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

Intestinal Status

27. Bowel Movement Frequency

<1 time per day

1-2 times per day

3 or more times per day

28. Bowel Movement Consistency

Soft and well formed

Often float

Difficult to pass

Diarrhea

Thin, long, or narrow

Small and hard

Loose but not watery

Alternating between hard and loose

29. Bowel Movement Color

Medium brown

Very dark or black

Greenish

Blood is visible

Variable

Yellow, light brown

Chalky colored

Greasy, shiny

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

31. Have you ever had food poisoning? If yes, please describe in detail, including: Where were you? What did you treat it with? Do you feel like you fully recovered from it?

Potential Health Hazards

32. To your knowledge, have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?

33. Do odors affect you?

34. Are you or have you been exposed to second-hand smoke?

35. Are you currently or have you been exposed to mold? If so, what is/was the source of the exposure and for how long have you been/were you exposed to mold, if known?

36. Have you used or abused alcohol, drugs, meds, tobacco, or caffeine? Do you still?

Oral Health History

37. How long since you last visited the dentist? What was the reason for that visit?

38. In the past 12 months, has a dentist or hygienist talked to you about your oral health, blood sugar, or other health concerns? Explain.

39. What is your current oral and dental regimen?

40. Do you have any mercury amalgams? If no, were they removed? If so, how?

41. Have you had any root canals? If yes, how many and when?

42. Do you have any concerns about your oral or dental health? Gums bleed after flossing, receding gums?

43. Is there anything else about your current oral or dental health or health history that you'd like us to know?

Sleep History

44. Are you satisfied with your sleep?

45. Do you stay awake all day without dozing?

46. Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.?

47. Do you fall asleep in less than 30 minutes?

48. Do you sleep between 6 and 8 hours per night?

49. Is there anything else you would like us to know about your sleep?

Reproductive Hormone History

If you do not have female reproductive organs please skip to question 57.

50. How old were you when you first got your period?

51. How are/were your menses? Do/did you have PMS? Painful periods? If so, explain.

52. In the second half of your cycle, do you experience any symptoms of breast tenderness, water retention, or irritability?

53. Have you experienced any yeast infections or urinary tract infections? Are they regular?

54. Have you/do you still take birth control pills? If so, please list length of time and type.

55. Have you had any problems with conception or pregnancy?

56. Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here.

Mental Health Status

57. How are your moods in general? Do you experience more anxiety, depression, or anger than you would like?

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

59. At what point in your life did you feel best? Why?

Other

60. Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? If no, explain.

61. Who in your family or on your health care team will be most supportive of you making dietary change?

62. What role does spirituality play in your life?

63. Please describe any other information you think would be useful in helping to address your health concern(s).

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