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Home New Patient Intake Form

New Patient Intake Form

of

1Personal Information

2Initial Consultation

3Lifestyle Habits

4Symptoms

5History

6Acknowledgements

Personal Information
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- Patient’s full name*
- Patient’s date of birth*
  MM slash DD slash YYYY
- Referred by
- Gender*
  - Female
  - Male
- Your goal is to (select all that apply):
  - Feel Better
  - Perform Better
  - Look Better
Contact info
- Street Address
- City
- State
- ZIP Code
- Phone**
- E-mail*
Lifestyle
- Occupation
- Employer
- Relationships Status*
  - Have a partner
  - Single
  - Other
Parameters
Current Weight
- Current Weight*
Your height (feet & inches)
- Height*
Dominant Wrist (inches)
- inches*
Blood
- Blood Type*
- Blood Type*
  - A
  - B
  - AB
  - O
  - I don’t know
RH Factor*
- RH Factor*
  - +
  - -
  - I don’t know
Activity Level
- Activity level
  - Sedentary (little or no exercise - desk job)
  - Light Activity (light exercise – sports 1 - 3 days per week)
  - Moderate Activity (moderate exercise - sports 3 - 5 days per week)
  - Very Active (hard exercise – sports 6 - 7 days per week)
  - Extra Active (hard daily exercise – sports and physical job)
Select Any Food Components You Avoid
- Food Component Reactions, Toxins and Junk Food
  - Amines
  - Caffeine
  - Eggs
  - Shellfish
  - Salicylates
  - Soy
  - Refined sugars
  - Harmful Fats
  - Alcohol
  - Yeast
  - Sulfites
  - Theobromine
  - Non-food items (synthetics)
  - Dairy (casein & lactose)
  - Fluoride/Chlorine
  - Gluten & Gliadin
  - Citrus Fruits
  - Carcinogens & Toxins
  - Glutamates
  - Pesticides (for organic diets)
  - Mercury Contaminated Foods
Ethnic & Vegetarian Intolerances
- Ethnic & Vegetarian Intolerances
  - Red Meat
  - Dairy Foods
  - Eggs and Egg Products
  - Fish and Seafood
  - Poultry
  - Non-Hindu Foods
  - Non-Kosher Foods
  - Non-Muslim Foods

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Initial Consultation Questionnaire
- What is your main health concern?
- What drew you to nutritional counseling?
- What is keeping you from optimal health?
- In what way could it all be better?
- What has worked for you in the past?
- What changed?
Cravings
- Cravings
  - I have specific cravings
- What do you crave?
- How often and when?
- How does it make you feel?
- Does it make you feel better or worse?
Stress & food
- In your relationship to food and health, where do you get confused?
- How does stress affect your relationship to food?
- What is your stress level on a scale of 1 - 10?*
  Please enter a number from 1 to 10.
Your body
- How does stress manifest in your body?
- What do you do to pamper yourself, unwind? How often?
- Is there anything that you’d like to be doing for yourself that you’re not?
- What gets in the way of doing these things?
- How would you feel if you were doing this thing on a regular basis?
Goals
- Where would you like to see your health in 3 months, 6 months, or 1 year?*
- What are your 3 BIGGEST obstacles to being in your peak health?*
- What prescription medications are you currently taking?*
- What nutritional supplements are you currently taking?*
- What questions or topics would you MOST like to know more about?
- What is the ONE thing you could be doing for yourself that you know would have a significant impact on your health and well-being?

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Lifestyle Habits
Breakfast
- Examples of a “good” breakfast*
- Examples of a “typical” breakfast*
- Examples of a “bad” breakfast*
Snack before lunch
- Examples of a “good” snack #1*
- Examples of a “typical” snack #1*
- Examples of a “bad” snack #1*
Lunch
- Examples of a “good” lunch*
- Examples of a “typical” lunch*
- Examples of a “bad” lunch*
Snack before dinner
- Examples of a “good” snack #2*
- Examples of a “typical” snack #2*
- Examples of a “bad” snack #2*
Dinner
- Examples of a “good” dinner*
- Examples of a “typical” dinner*
- Examples of a “bad” dinner*
Snack after dinner
- Examples of a “good” snack #3*
- Examples of a “typical” snack #3*
- Examples of a “bad” snack #3*
Water
- A "GOOD" day*
- A "TYPICAL" day*
- A "BAD" day*
Calories per day
- A "GOOD" day
- A "TYPICAL" day
- A "BAD" day
Health & Lifestyle
- A "GOOD" day
- A "TYPICAL" day
- A "BAD" day
Sleep
- A "GOOD" day
- A "BAD" day
Work
- A "GOOD" day
- A "TYPICAL" day
- A "BAD" day
Self-care
- A "GOOD" day
- A "BAD" day
Leisure
- A "GOOD" day
- A "BAD" day
Relaxation
- A "GOOD" day
- A "TYPICAL" day
- A "BAD" day

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Symptoms that you experience
For each section, simply check the boxes next to any symptoms or conditions that apply to you.
Body Systems Questionnaire
- Symptoms that you experience
  - Abdominal pain or discomfort
  - Dark circles or puffiness under eyes
  - General weakness or chronic illness
  - Acid indigestion or heartburn
  - Dizziness or light headedness
  - Heart problems
  - Asthma
  - Excess mucus production
  - High cholesterol
  - Brittle fingernails
  - Fatigue in the afternoons
  - Infertility
  - Cold hands and feet
  - Food allergies
  - Itchy nose and ears
  - Congested air passages
  - Frequent backache
  - Leg cramps or pains
  - Cravings for fat or high fat diet
  - Frequent infections
  - Loose stool or diarrhea
  - Cravings for sugar
- - Loss of sexual desire
  - Stiff, aching, or painful muscles
  - Absent - mindedness or forgetfulness
  - Menstrual problems (females)
  - Ulcers
  - Anxiety, nervousness or tension
  - Migraine headaches
  - Urinating at night
  - Bad breath or body odor
  - Osteoporosis
  - Waking up frequently at night
  - Burning or painful urination
  - Prostate problems (males)
  - Weak legs, knees or ankles
  - Colitis or other bowel irritations
  - Scant or excessive urination
  - Wounds won't heal on extremities, i.e. arms, hands, legs, feet
  - Constipation or dry stools
  - Sinus headaches
- - Difficulty getting to sleep
  - Hay Fever
  - Less than 1 bowel elimination per day
  - Dry Skin
  - High blood pressure
  - Loss of appetite or poor appetite
  - Family history of heart disease
  - Impotency (males only)
  - Menopause problems (females)
  - Fatigue or low energy levels
  - Intestinal gas or bloating
  - Mental / emotional stress
  - Food sits heavy on stomach after eating
  - Joint pain, arthritis or gout
  - Pale complexion and/or anemia
  - Frequent cough
  - Muddled thinking, confusion or mental sluggishness
  - Restless dreams or nightmares
  - Frequent urinary tract infections
- - Sinus congestion
  - Skin problems (acne, rashes, etc.)
  - Underweight or unable to gain weight
  - Water retention or edema
  - Swollen lymph glands
  - Varicose veins
  - Wheezing or shortness of breath
- Specify

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Conditions and Complaints
Please select all that apply to you
- Conditions and Complaints
  - Acne (vulgaris)
  - Atherosclerosis
  - Burning Feet
  - Adrenal Hypo-function
  - Autism
  - Bursitis
  - Alcoholism
  - Benign Prostatic Hyperplasia
  - Canker Sores
  - Amenorrhea
  - Biliary Stasis
  - Cataracts
  - Bleeding Gums
  - Chemotherapy Support
  - Excessive Appetite
  - Bone Spurs
  - Chicken Pox
  - Arteriosclerosis
  - Bronchitis
  - Elevated Cholesterol (total)
- Specify
- - Colic
  - Diabetes (type I)
  - Enuresis (bed wetting)
  - Constipation
  - Diarrhea
  - Epstein Barr Virus (EBV)
  - Copper Toxicity
  - Drug Addiction
  - Fibrocystic Breast Disease
  - Cytomegalovirus (CMV)
  - Dry Skin
  - Flatulence
  - Crohn's Disease
  - Dyspepsia (indigestion)
  - Gallbladder Dysfunction
  - Dental Caries (cavities)
  - Eczema
  - GERD
  - Dermatitis
  - Emphysema
  - Goiter
- - Halitosis
  - High Triglycerides
  - Impotence (male)
  - Headaches (non - migraine)
  - Hyperglycemia
  - Infection (bacterial)
  - Heavy Metal Toxicity
  - Hypertension
  - Infection (prostate)
  - Hemophilia
  - Hypochlorhydria
  - Infection (sinus)
  - Hepatic Cirrhosis
  - Hypotension
  - Infection (viral)
  - Hepatitis
  - Idiopathic Thrombocytopenic Purpura
  - Infertility (female)
  - Hiatal Hernia
  - Ileocecal Valve Dysfunction
  - Inflammation (general)
- Single worst problem from conditions/complaints listed above

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Acknowledgements
Please tick all the boxes to acknowledge scheduling policies.
- Additional Comments
- Customized Nutrition appointments cancelled with less than 48 hours’ notice will be charged the full price of your visit.
  - Customized Nutrition appointments cancelled with less than 48 hours’ notice will be charged the full price of your visit.
  - If you need to reschedule or cancel your appointment: please call or text 858-228-3644 or email [email protected].
- We appreciate your cooperation
- This policy serves to help defray the increased overhead resulting from such unusable appointment slots. It is also hoped that it helps to create a sense of personal accountability, which is critical in the development of a healthy lifestyle. We believe that being responsible for one’s own health improves one’s health. We understand that at times there may be extenuating circumstances such as true family or work related emergencies that may prevent you from keeping your scheduled appointment. All we ask is that you inform us as early as possible about such changes and we are more than willing to be flexible. We appreciate your cooperation in helping our office to schedule and accommodate as many patients during the day as possible as well as helping our office to run smoothly for the convenience of all.
- I’ve read the information above and agree to the terms**
  - I’ve read the information above and agree to the terms
- Please type your full name*
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Perform Better

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Corporate Wellness

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Location

7220 Avenida Encinas,
Suite 110-B
Carlsbad, CA 92011

Working hours

Office hours :

Weekdays 8:00 am to 5:00 pm

Saturday 8:00 am to 1:00 pm

Coaching Hours:

Weekdays 6:00 am to 7:00 pm

Saturday 8:00 am to 2:00 pm

Contacts

Office/Scheduling: 858 228 3644

Fax: 858-228-3641

E-mail: [email protected]

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  Office Hours : Monday — Thursday 9:30am to 6:00pm
  Friday 9:30am to 2:00pm
  
  Coaching Hours : Weekdays 6:00am to 7:00pm
  Saturday 9:30am to 2:00pm
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