Intake Form – Step Up To The Plate Nutrition

New Client Intake Form

The first step on the path to wellness!
This form is 7 pages long, and should take approximately 15-20 minutes to fill out.

Use your home computer to fill out this intake form. It's best to not to use a public computer, such as at the library.

Please don't worry if you are unable to recall exact dates or names of medications you have taken. We will be discussing this information and I will be able to get additional clarity through our consultation conversation.
1: Your Contact Info

Let's start with the basics. Who are you, and how can we get in touch?
Name

First Name Last Name

Address

3: Health Goals & History

Let's talk about how you're feeling now, and how you'd like to be feeling in the future.
List one to five health concerns/goals you would like to attain, in order of priority.
Please note how long these have been a concern to you.
What could get in the way of your plan of action?
Please note any current health diagnosis or upcoming surgery.
Explain any past experience with other practitioners (i.e., Chiropractor, Naturopath, Therapist, Homeopath, Massage)
Please list all past conditions or health information that you have experienced, including all: surgeries, illnesses, vaccinations, physical trauma/accidents.
Please provide approximate time frames, to the best of your knowledge.
Family Health History

Please note any significant health issues for the following family members.
Mother's history
Father's history
Siblings' history
Dental Health
Do you have amalgam/silver fillings? How many?
Have you had any amalgam/silver fillings removed? How many, and when?
Have you had any root canals? How many?
Have you had any teeth removed? Which ones, and when?
Do you have any crowns or other metals (braces, retainers, partials)?

4: Medications & Nutritional Intake

Let's talk about what you're currently consuming.
List any medications you are taking now, or have taken in the past. Please include the reason for taking, as well as how long.
List any supplements you currently taking, including herbal remedies and drink powders. Please include the amount you are taking, and for how long.
Do you have any known allergies?
What foods do you crave?
Daily Consumption

Please indicate your daily consumption of the following items.
Black tea
# of cups per day
Green tea
# of cups per day
Herbal tea
# of cups per day
Coffee
# of cups per day
Alcohol
# of glasses/bottles per day
Water
# of cups per day
Fruit juice
# of cups per day
Pop
# of cans/glasses per day
Sugar
# of teaspoons (tsp) per day
Artificial sweetener
# of teaspoons (tsp) per day
Milk
# of cups per day
Cream
# of tablespoons (tbsp) per day
Butter
# of tablespoons (tbsp) per day
Margarine
# of tablespoons (tbsp) per day
Cheese
# of ounces (oz) or grams (gr) per day

Now create your own JotForm - It's free! Create your own JotForm

New Client Intake Form