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Home
New Patient Intake Form
New Patient Intake Form
of
1
Personal Information
2
Initial Consultation
3
Lifestyle Habits
4
Symptoms
5
History
6
Acknowledgements
Personal Information
Hidden
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
Your relationships?*
Have a partner
Single
Other
Spouse/Partner's Name
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
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?*
*
Range Slider
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 like to see your health in 3 months, 6 months, 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?
Lifestyle Habits
Breakfast
Examples of “good” breakfast
*
Examples of “typical” breakfast
*
Examples of “bad” breakfast
*
Snack before lunch
Examples of “good” snack #1
*
Examples of “typical” snack #1
*
Examples of “bad” snack #1
*
Lunch
Examples of “good” lunch
*
Examples of “typical” lunch
*
Examples of “bad” lunch
*
Snack before dinner
Examples of “good” snack #2
*
Examples of “typical” snack #2
*
Examples of “bad” snack #2
*
Dinner
Examples of “good” dinner
*
Examples of “typical” dinner
*
Examples of “bad” dinner
*
Snack after dinner
Examples of “good” snack #3
*
Examples of “typical” snack #3
*
Examples of “bad” snack #3
*
Water
A "GOOD" day
*
Typical day
*
A "BAD" day
*
Calories per day
A "GOOD" day
Typical day
A "BAD" day
Health & Lifestyle
A "GOOD" day
Typical day
A "BAD" day
Sleep
A "GOOD" day
A "BAD" day
Work
A "GOOD" day
Typical day
A "BAD" day
Selfcare
A "GOOD" day
A "BAD" day
Leisure
A "GOOD" day
A "BAD" day
Relaxation
A "GOOD" day
Typical day
A "BAD" day
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
Hayfever
Less than 1 bowel elimination per day
Dry Skin
High blood pressure
Loss of appetite or poor appetite
Family histo ry 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 or breath
Specify
Conditions and Complaints
Please mark the valid statement for you to determine whether you are a candidate for the Ideal Protein Weightloss Program.
Conditions and Complaints
Acne (vulgaris)
Atherosclerosis
Burning Feet
Adrenal Hypo - function
Autism
Bursitis
Alcoholism
Benign Prostatic Hyperplasia
Canker Sores
Amenorrhea
Biliary Stasis
Cataracts
AmenorrheaAngina Pectoris
Bleeding Gums
Chemotherapy Support
Appetite Excessive
Bone Spurs
Chicken Pox
Arteriosclerosis
Bronchitis
Cholesterol Elevated (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 Thrombo. Purpura
Infertility (female)
Hiatal Hernia
Ileocecal Valve Dysfunction
Inflammation (general)
Single worst problem from conditions/complaints list above
Acknowledgements
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
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Office Hours :
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Friday 9:30am to 2:00pm
Coaching Hours :
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Saturday 9:30am to 2:00pm
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