Intake Form Men

  • Personal Information

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  • Date*
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  • Name*
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  • Occupation*
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  • Date of Birth*
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  • What are your main health concerns in order of importance to you:*
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  • Current History

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  • What other therapies are you currently using?*
    Exercise
    Vitamins/Minerals
    Herbs
    Diet
    Meditation
    Reflexology
    Massage
    Osteopathy
    Naturopathic Doctor
    Acupuncture
    Homeopathy
    Chiropractor
    Prescription Meds
    Medical Doctor
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  • Other Therapies*
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  • What level of stress do you feel you are experiencing at this time in your life?*
    Minimal
    Average
    Considerable
    Unbearable
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  • How well do you handle stress?*
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  • Have you experienced any trauma or loss in the last 5 years?*
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  • What do you do for exercise?*
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  • On a scale of 1-10, how would you describe your energy levels?*
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  • Do you experience any lulls or highs in your energy levels throughout the day? If so, at what time?*
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  • How many hours on average do you sleep daily (including naps)?*
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  • What time do you go to sleep?*
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  • What time do you wake up?*
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  • Do you have trouble*
    Falling asleep
    Staying asleep
    Waking feeling rested?
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  • Current weight*
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  • Do you wish to gain weight?*
    Yes
    No
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  • Do you wish to lose weight?*
    Yes
    No
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  • What is your main motivation to change your weight?*
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  • Ideal weight*
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  • Medication and Supplement History

    Please list all supplements, herbs, homeopathic remedies, and medications you are currently taking:

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  • Medication/Supplement*
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  • Dosage*
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  • Since*
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  • Reason*
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  • Medical History

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  • Do you take antidepressants?*
    Yes
    No
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  • Have you taken antibiotics over the past five years?*
    Yes
    No
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  • Do you have any allergies or sensitivities?*
    Yes
    No
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  • How often do you have a bowel movement?*
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  • Do you strain to have a bowel movement?*
    Yes
    No
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  • Do you have loose bowel movements?*
    Yes
    No
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  • Please check any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), dates.*
    Cancer
    Heart Disease
    Hepatitis
    Venereal Disease
    Diabetes
    High Blood Pressure
    High Cholesterol
    Kidney Disease
    Thyroid Disease
    Prostate
    Depression
    Asthma
    Allergies
    Anemia
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  • Other Conditions*
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  • Briefly describe your symptoms*
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  • Family History

    Use F for Father, M for Mother, S for sibling, G for grandparent, O for other
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  • Allergies*
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  • Alcoholism*
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  • Arthritis*
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  • Asthma*
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  • Autoimmune disease*
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  • Cancer, type*
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  • Diabetes*
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  • Drug Abuse*
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  • Gall Bladder problems*
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  • Heart Disease*
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  • Hypertension*
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  • Intestinal disease*
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  • Kidney problems*
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  • Mental illness*
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  • Osteoporosis*
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  • Skin Conditions*
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  • Other (please list type as well):*
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  • Dietary Habits

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  • How many times a day do you eat?
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  • No. of Main meals*
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  • No. of Snacks*
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  • On a typical day, please outline what you would eat/drink:
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  • Breakfast:*
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  • Lunch:*
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  • Dinner:*
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  • Snacks:*
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  • Beverages:*
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  • How much water do you consume daily?*
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  • What are your favourite foods?*
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  • What foods, if any, do you crave?*
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  • Do you avoid certain foods? If so, why?*
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  • Do you experience any symptoms if meals are missed? Explain:*
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  • Do you experience any symptoms after meals? Explain*
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  • What percentage of your meals are home-cooked?*
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  • On a scale of 1-10, how willing are you to make changes and begin new habits when it comes to making choices about nutrition and lifestyle?*
    1
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  • What kind of outcome(s) are you hoping to achieve as a result of working together?*
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  • What excites you the most about achieving success in this area?*
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  • Do you have any questions?*
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  • Client Statement

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  • Client Statement*
    I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purpose of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.
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  • Name*
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  • Address*
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  • City*
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  • Province/State*
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  • Postal Code/Zip Code*
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  • Telephone*
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  • Email*
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  • Signature*
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