Client Intake Form RMR CLIENT INTAKE FORM TEST Step 1 of 5 20% Personal InformationName* First Last Birth Date* Date Format: MM slash DD slash YYYY Street Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OccupationPhone*Email* Height(in feet and inches)Weight(pounds)Dominant Wrist(inches)Sex*FMBlood Type*ABABODon't knowRH Factor*+-Don't knowGoals Look Better Feel Better Perform Better Activity Level*Sedentary (little or no exercise, desk job or bed ridden)Light Activity (light exercise – sports 1 - 3 days per week)Moderate Activity (moderate ex.: sports 3 - 5 days/week)Very Active (hard exercise – sports 6 - 7 days per week)Extra Active (hard daily exercise – sports and physical job)Food Component Reactions Toxins and Junk FoodCheck all that apply 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 IntolerancesCheck all that are REMOVED from your diet Red Meat Dairy Foods Eggs and Egg Products Fish and Seafood Poultry Non-Hindu Foods Non-Kosher Foods Non-Muslim Foods Save and Continue Later Initial Consultation QuestionnaireWhat is your main health concern?What has worked for you in the past?Do you have any specific cravings?A - When do you crave that?B - How often?C - How does it make you feel?D - Does it make you feel better or worse?Where would like to see your health in 3 months, 6 months, 1 year?What nutritional supplements are you currently taking?What prescription medications are you currently taking?What are your 3 BIGGEST obstacles to being in your peak health?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?What questions or topics would you MOST like to know more about? Save and Continue Later Lifestyle Habits Let's get an idea of where you're at and what you've been doing.NutritionBREAKFAST: A "GOOD" dayBREAKFAST: A "BAD" dayBREAKFAST: A typical daySNACK 1: A "GOOD" daySNACK 1: A "BAD" daySNACK 1: A typical dayLUNCH: A "GOOD" dayLUNCH: A "BAD" dayLUNCH: A typical daySNACK 2: A "GOOD" daySNACK 2: A "BAD" daySNACK 2: A typical dayDINNER: A "GOOD" dayDINNER: A "BAD" dayDINNER: A typical daySNACK 3: A "GOOD" daySNACK 3: A "BAD" daySNACK 3: A typical dayWATER (oz): A "GOOD" dayWATER (oz): A "BAD" dayWATER (oz): A typical dayCALORIES: A "GOOD" dayOk to guessCALORIES: A "BAD" dayOK to guessCALORIES: A typical dayOK to guessExerciseEXERCISE: "GOOD" dayEXERCISE: A "BAD" dayEXERCISE: A typical dayHealth & LifestyleSTRESS LEVEL: A "GOOD" day*1 is low and 10 is high12345678910STRESS LEVEL: A "BAD" day*1 is low and 10 is high12345678910STRESS LEVEL: A typical day*1 is low and 10 is high12345678910SLEEP (hrs): A "GOOD" dayOk to guessSLEEP (hrs): A "BAD" dayOk to guessSLEEP (hrs): A typical dayOk to guessWORK (hrs): A "GOOD" dayOk to guessWORK (hrs): A "BAD" dayOk to guessWORK (hrs): A typical dayOk to guessSELF CARE: A "GOOD" daySELF CARE: A "BAD" daySELF CARE: A typical dayLEISURE: A "GOOD" dayActivities/HobbiesLEISURE: A "BAD" dayActivities/HobbiesLEISURE: A typical dayActivities/HobbiesRELAXATION: "GOOD" dayRELAXATION: A "BAD" dayRELAXATION: A typical day Save and Continue Later Body Systems QuestionnaireSymptoms that you experienceCheck all that apply Abdominal pain or discomfort Absent - mindedness or forgetfulness Acid indigestion or heartburn Anxiety, nervousness or tension Asthma Bad breath or body odor Brittle fingernails Burning or painful urination Cold hands and feet Colitis or other bowel irritations Congested air passages Constipation or dry stools Cravings for fat or high fat diet Cravings for sugar Dark circles or puffiness under eyes Difficulty getting to sleep Dizziness or light headedness Dry Skin Excess mucus production Family histo ry of heart disease Fatigue in the afternoons Fatigue or low energy levels Food allergies Food sits heavy on stomach after eating Frequent backache Frequent cough Frequent infections Frequent urinary tract infections General weakness or chronic illness Hayfever Heart problems High blood pressure High cholesterol Impotency (males only) Infertility Intestinal gas or bloating Itchy nose and ears Joint pain, arthritis or gout Leg cramps or pains Less than 1 bowel elimination per day Loose stool or diarrhea Loss of appetite or poor appetite Loss of sexual desire Menopause problems (females) Menstrual problems (females) Mental / emotional stress Migraine headaches Muddled thinking, confusion or mental sluggishness Osteoporosis Pale complexion and/or anemia Prostate problems (males) Restless dreams or nightmares Scant or excessive urination Sinus congestion Sinus headaches Skin problems (acne, rashes, etc.) Stiff, aching, or painful muscles Swollen lymph glands Ulcers Underweight or unable to gain weight Urinating at night Varicose veins Waking up frequently at night Water retention or edema Weak legs, knees or ankles Wheezing or shortness or breath Wounds won't heal on extremities, i.e. arms, hands, legs, feet Conditions and ComplaintsSelect only the most significant issues Acne (vulgaris) Adrenal Hyper - function Adrenal Hypo - function AIDS or HIV Alcoholism Alzheimer's Disease Amenorrhea Anemia (macro & microcytic) Angina Pectoris Anxiety Appetite Excessive Appetite Reduced Arteriosclerosis Asthma Atherosclerosis Attention Deficit Disorder Autism Bell's Palsy Benign Prostatic Hyperplasia Biliary Insufficiency Biliary Stasis Bipolar Disorder Bleeding Gums Body Odor Bone Spurs Bradycardia Bronchitis Bruxism Burning Feet Burns (1st, 2nd, 3rd degree) Bursitis Cancer ( prevention) Canker Sores Cardiac Arrhythmia Cataracts Celiac Disease (sprue Chemotherapy Support Cervical Dysplasia Chicken Pox Cholesterol Decreased (total) Cholesterol Elevated (total) Chronic Fatigue Syndrome Colic (mother's & child's diet) Congestive Heart Failure Constipation COPD Copper toxicity Coronary Artery Disease Crohn's Disease Cystic Fibrosis Cytomegalovirus (CMV) Degenerative Joint Disease Dental Caries (cavities) Depression Dermatitis Detoxification Support Diabetes (type I) Diabetes (type II) Diarrhea Diverticulosis Drug Addiction Dry Eyes (Sjögren's synd.) Dry Skin Dysmenorrhea Dyspepsia (indigestion) Ear Infections Eczema Edema Emphysema Endometriosis Enuresis (bed wetting) Epilepsy (seizure disorders) Epstein Barr Virus (EBV) Fever Fibrocystic Breast Disease Fibromyalgia Flatulence Fractures Gallbladder Dysfunction Gallstones GERD Glaucoma Goiter Grave's Disease Halitosis Hashimoto's Disease Headaches (non - migraine) Heal Spurs Heavy Metal Toxicity Hemachromatosis Hemophilia Hemorrhoids Hepatic Cirrhosis Hepatic Disease Support Hepatitis Herpes Simplex (HSV - 1) Hiatal Hernia High Cholesterol (LDL) High Triglycerides Homocysteine Elevated Hyperglycemia Hyperkinesis Hypertension Hyperthyroidism Hypochlorhydria Hypoglycemia Hypotension Hypothyroidism Idiopathic Thrombo. Purpura Ileitis Ileocecal Valve Dysfunction Immune Deficiency Impotence (male) Incontinence Infection (bacterial) Infection (parasitic) Infection (prostate) Infection (respiratory) Infection (sinus) Infection (urinary) Infection (viral) Infection (yeast/fungal) Infertility (female) Infertility (male) Inflamma tion (general) Inflammation (vascular) Influenza (flu) Insomnia Interstitial Cystitis Irritable Bowel Syndrome Joint Pain Kidney Stones Lactose Intolerance Liver - Colon Detoxification Low Cholesterol (HDL) Lung Problems (non - specific) Lupus Lyme Disease Macular Degeneration Manic De pression Measles Meniere's Disease Menorrhagia Menstrual Cramps Metabolic Syndrome Migraine Headache Mitral Valve Prolapse Mononucleosis Mucous (allergy related) Mucous (respiratory/sinus) Multiple Scle rosis (MS) Mumps Muscular Dystrophy Myasthenia Gravis Nausea Nausea (during pregnancy) Obesity Osteoarthritis Osteoporosis Pain (musculoskeletal) Pancreatitis Panic Disorder Parasthesia Parkinson's Disease PCOS Peptic/Duodenal Ulcer Periodontal Disease Phlebitis Phobias Pituitary Dysfunction PMS Pneumonia Polycythemia (secondary) Pregnancy (gen. support) Pregnancy & Yeast Infec. Psoriasis Purpura Simplex Radiation Therapy Support Raynaud's Disease Reduced Circulation Rhinovirus (common cold) Rheumatoid Arthritis Rhinovirus (comm.cold) Schizophrenia Sciatica Scleroderma Seborrhea Sex Drive Diminished (F) Sex Drive Diminished (M) Skin R ashes Sperm Count Reduced Stroke (recovery support) Sulfite Allergy - Sensitivity Surgery Support (pre/ post) Tachycardia Tendonitis Thrombophlebitis Tinea (ringworm) Tinnitus Trigeminal Neuralgia Tuberculosis (TB) Ulcerative Colitis Urticaria (hives) Uterine Fibroids Varicose Veins Vertigo Vitiligo Wilson's Syndrome Xerophthalmia Single worst problem from conditions/complaints list above Save and Continue Later Additional CommentsAcknowledgementsMissed Appointments and Cancellations PolicyWhen a patient fails to show for a scheduled appointment or cancels with short notice, we are unable to offer that time to any other patients who might need it. This unusable time results in increased overhead. There will be a charge for missed appointments or those cancelled with less than 24 hours’ notice. Our charge is whatever the original visit would have cost . Due to limited availability, our cancellation policy is as follows: . Ideal Protein appointments cancelled with less than 24 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 firstname.lastname@example.org. 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.Please type your full name*CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.