New Client Intake

Women's Health History

All of your information will remain confidential between you and Andrea.

Personal Information

First Name *

Last Name *

Email *

How often do you check email

Home Phone

Work Phone

Mobile Phone

Age

Height

Date of Birth

Place of Birth

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different?

If so, what?

Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Health Information

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you feel best?

Any serious illnesses, hospitalizations, or injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

How is your sleep?

How many hours of sleep per night?

Do you wake up at night?

Why do you wake up?

Any pain, stiffness, or swelling?

Constipation / Diarrhea / Gas?

Allergies or sensitivities? Please explain

Women's Health

Are your periods regular?

How many days is your flow?

How frequent are your periods?

Painful or symptomatic? Please explain

Reached or approaching menopause? Please explain

Birth control history

Do you experience yeast infections or UTIs? Please explain

Medical Information

Do you take any supplements or medications? Please list

Any healers, helpers, or therapies you are involved with? Please list

What role do sports and exercise play in your life?

Food Information — Childhood

What foods did you eat often as a child?

Breakfast (childhood)

Lunch (childhood)

Dinner (childhood)

Snacks (childhood)

Liquids (childhood)

Will family and/or friends be supportive of food and lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where do you get the rest of your food from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should do to improve my health is

Current Food Patterns

Breakfast (current)

Lunch (current)

Dinner (current)

Snacks (current)

Liquids (current)

Additional Comments

Anything else you would like to share?

Type your name (signature) *

Quick check — please answer this to submit:

What is 5 + 2?

Your information is strictly confidential.