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CLIENT INTAKE FORM
The following form will help to assess your overall health status. Our ability to draw effective
conclusions about your present state of health and how to improve it depends, to a significant
extent, on your ability to respond thoughtfully and accurately to both the questions below and
those posed during your consultations. These questions will help to identify underlying causes
of the nutritional imbalances and will also assist in formulating an effective plan specific to
your goals/concerns.
PERSONAL INFORMATION
First Name: Last Name:
Address:
City:
Cell Phone: Email:
Date of Birth: _____ / _____ / _____ Place of Birth:
mo day year
Occupation: ____ Time at Computer:
Marital Status: Number of Children: _____________________
Height: ___ ft ____ in Weight: lbs Pets:
Average Sleep: _______hours/day Time: am/pm
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CURRENT HEALTH CONCERNS/GOALS
Please rank current and ongoing concerns/goals by priority and fill in the other boxes as
completely as possible:
The challenge(s) I feel I have with making changes to improve my health is/are:
(1)
(2)
(3)
CONCERN/GOAL Description
Mild/Moderate/
Severe
Treatment
Approach
Success
Example: Dry Skin
Moderate
Elimination Diet
Moderate
(1)
(2)
(3)
Rank the importance of immediately improving your
health:
Low
1
2
3
4
5
High
Rank your current motivation to accomplish your goals:
Low
1
2
3
4
5
High
Rank your openness to be coached to optimal health:
Low
1
2
3
4
5
High
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I will address these challenges by:
(1)
(2)
(3)
MEDICAL AND SURGICAL HISTORY!
!
Please list any past medical and surgical procedures:
FAMILY HISTORY
!
Please indicate any current or historic family condition(s) or illnesses. Include maternal and
paternal grandparents if possible.
Surgery
Date
Comments
Example: Appendix removed
September
7 amalgams done
Relation
Illnesses
Father
Mother
Sibling
Sibling
Maternal grandfather
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MEDICATION HISTORY!
!
Please indicate if you use any of the following medications.
OTHER MEDICATIONS & VACCINATIONS
Maternal grandmother
Paternal grandfather
Paternal grandmother
Antacids
Laxatives
Rarely
Rarely
Weekly
Weekly
Daily
Daily
Antibiotics
Never
1 or less/
year
2+/
year
Oral
Antifungals
Never
Once
2+
Acid Inhibitors (eg. Zantac, Losec)
Never
Occasionall
y
Daily
Tylenol
Never
Rarely
Frequently
AntiZinflammatory (eg. Advil, Aspirin)
Never
Rarely
Frequently
Medicine/Vaccine Name and Reason
Dosage
Date Started
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Are you allergic to any medications? Yes No
If yes, please list medication and the nature of the reaction you had to it:
SUPPLEMENT HISTORY
!
List all vitamins, minerals, and other nutritional supplements you are taking now.
DIETARY INFORMATION
!
Do you have any food cravings? Yes No
If yes, do you crave sweets? ! Breads/pastas? Salty foods? !
Are you on a special diet? Yes No
If yes, please specify: ___________________________________________________________
Do you like to cook at home? Yes No If yes, how often? __________ times/week
Vitamin/Mineral/Herb/Supplement Name
Dosage/Frequency
Status/Date Started
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Please carefully list an average day’s food consumption. Try to be as detailed as possible, and
include the number of glasses of water, juice, coffee, or other beverages in the space provided.
MEALS:
Breakfast ( am)
Lunch ( am/pm)
Dinner (_______pm)
SNACKS:
Mid Morning:
Mid Afternoon: _
After Dinner: ___________________________________________________________
Please indicate if you consume any of the following and indicate number of servings per
week:
BEVERAGES:
Item: ______________________________
Qty: (oz./L)
Time of Day:
Item: ______________________________
Qty: (oz./L)
Time of Day:
Item: ______________________________
Qty: (oz./L)
Time of Day:
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Do you consume alcohol? Yes No
If so, how often do you now drink alcohol? times per week
Have you ever used recreational drugs? Yes No
If so, which drugs presently?
If so, which drugs in the past? ____________________
Have you ever used tobacco? Yes No
If yes, number of years as a nicotine user _____ Amount per day _____ Year quit _________
WOMEN’S HEALTH INFORMATION
!
Age of menstruation; onset cessation _
Regular Yes No Length
PMS Symptoms:
Menopausal symptoms:
Fertility issues
Pregnancy History: # of Pregnancies # of Children
Substance
Number of Servings (per week)
Serving Size (approx.)
Luncheon meats
Candy
Margarine
Soft drinks
Coffee
Sweets/pastries
Fast foods
Fried foods
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DIGESTIVE HEALTH INFORMATION
Do you have any known food allergies? Yes No
If yes, please list
Do you have any known environmental or chemical allergies? Yes No
If yes, please list
BOWEL MOVEMENTS
Frequency
"
Consistency
"
More than 3 times a day
Soft and well formed
2 to 3 times a day
Small and hard
1 time a day
Loose but not watery
3 to 5 times a week
Alternating between
hard & loose/watery
2 or fewer times a week
Pencil thin
General Colour of Stool:
INTESTINAL GAS
Daily
Present with pain
Occasionally
Foul smelling
Excessive
Little odor
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LIFESTYLE INFORMATION
!
Please rank you level of satisfaction with the following areas of your life:
Where would you rank your overall stress level? Low 1 2 3 4 5 High
Rank your sources of stress in priority:
How do you deal with your stress? _________________________________________________
Do you exercise regularly? Yes No
If so, how many times a week? When you exercise, how long is each session?
1x 15 min
2x 16-30 min
3x 31-45 min
4x or more 45min
Please list the type of exercise:
Very Well
Fair
Poorly
Very Poorly
N/A
At school
In your job
In your social life
With your close friends
With your significant other
With your children
With your parents
Jogging
Walking
Hiking
Cycling
Snow
sports
Water
sports
Strength
Aerobics
Martial Arts
Other
(comment)
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CLIENT STATEMENT!
!
I hereby attest to the following:
1. I fully understand that Vanessa Vorbach is not a medical doctor and
I am not visiting them for medical diagnostic or treatment procedures.
2. The services provided by Vanessa Vorbach are at all times
restricted to
consultation on the subject of nutritional matters intended for general nutritional
wellbeing and do not involve the diagnosing, prognosticating, treatment, or
prescribing of remedies for the treatment of any disease, or any licensed or controlled
act which may constitute the practice of medicine in this province.
3. This agreement is being signed voluntarily and not under duress of any kind.
Client Name
Signature Date
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