Kalimashs Digital Practice Intake Form
Name :
Age :
Address :
Telephone (best) :
Email :
Reason for visit (prioritized):
1.
2.
3.
Nutritional data:
How many ounces of water/day? :
What kind? :
What other beverages do you drink and how often do you drink them? :
Do you use artificial sweeteners? :
If so, which ones? :
How often? :
In what? :
Do you eat breakfast? :
If so, what? :
How much of the following do you consume?
(example: 1D = 1/day, 2W = 2/week, 3M = 3/month)
Fresh fruit . Raw vegetables . Fermented foods .
Fast foods . Meat . Eggs . Dairy. Cooked Veg .
What do you crave?
What foods do you dislike the most?
Why?
Timing:
What is the first thing you do when you get up in the morning?
What time do you eat your first meal? .Last meal?
Which meal is your largest of the day?
Describe your typical largest meal.
Movements:
Do you exercise/move/participate in fun sweaty activity?
If so, what and how often?
Do you look forward to it?
How do you feel when you are finished?
Sleep:
What time do you go to bed?
How long do you sleep?
Do you wake often?
If so, why and at what time(s)?
Do you feel rested when you wake up for the day?
Do you have pain when you first get up?
If so, where?
Does it go away upon moving?
Eliminations:
Do you have daily bowel eliminations?
If yes, how many per day?
If no, please describe your elimination pattern.
Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided. BSC #
Color
Females:
Are you post-menopausal?
If yes, at what age did you enter menopause?
What were the characteristics of your menopausal experience?
Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?
Are you now, or in the near future, planning to become pregnant?
Is your menstrual cycle regular?
Is it longer or shorter than 28 days?
Is your flow longer or shorter than 5 days?
Do you have cramps or clotting?
How would you describe the color of your menses?
Check the type of PMS symptoms you often experience:
Abdominal Cramping
Gastrointestinal
Cramping
Cyclical Headache
Insomnia
Mood Swings
Anxiety/Tension
Food Cravings
Supplements/medications:
Do you take any supplements?
If so, what, how often and why?
Do you take any OTC medications routinely (such pain reliever or allergy medicine)?
If so, what and how often?
Do you take prescription medications (prescribed by a licensed medical professional?)
If so, what and how often?
Medical history:
Have you had any surgeries?
If so, what and when?
Have you received any diagnoses from licensed medical professionals?
If so, what and when?
Are you experiencing symptoms that are not connected with a medical diagnosis?
If yes, please explain:
If so, what and how often?
Naturopathic history:
Have you ever been in consultation with a naturopath?
If so, why?
How long ago?
What was suggested?
Did you experience a good outcome?
What did you like about it?
What wasn’t as successful for you?
Do you have regular adjustments with a chiropractor?
Do you have regular body work/massages?
Please check all with which you are familiar:
Homeopathy
Bach Flowers/flower remedies
Probiotics
Aromatherapy
Muscle response testing
Herbals
Sports nutrition
Enzymes
Please upload 2 images each for Left IRIS.
Please upload 2 images each for Right IRIS.
I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease.
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