Health History Intake Form for Functional NutriGenomic Interpretation
Please complete this form to the best of your ability. The more details you provide, the more personalized I can make your interpretation. This form must be completed before I will conduct a genetic interpretation for you.

*Note: According to the HIPAA Journal, this form is HIPAA compliant. If there are any sections that you do not feel comfortable sharing via this form, please email the information to me at info@JaclynDowns.com. Thank you!
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Email *
Name *
Email *
Age *
Occupation *
How did you hear about me? *
Optional: What is your address? (I am asking so I can pull it up on Google Maps/Earth and see what environmental factors may be affecting you)
Please list any health concerns in order of importance
 *
How long have they been going on for you? *
What have you tried that has NOT worked to help this situation? *
What have you tried that has worked, even if just a little? *
What are your goals for utilizing this service?
 *
Phone number *
Date of birth *
MM
/
DD
/
YYYY
Do you have any medical conditions that have been diagnosed by a doctor? If yes, please explain.
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Have you had any prior surgeries? If yes, please describe and give approximate date.
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Are you pregnant or nursing? (Type "N/A" if male for all menstrual-related questions)
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How often do you get periods? (how long is your cycle?)
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How long do they last?
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Are they heavy, clotty, painful, darker in color, etc.?
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Are your symptoms worse around ovulation?
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Historically, how were your periods (as opposed to currently)?
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Anything else you'd like to add about your period/menstrual health?
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How often do you have a bowel movement?
 *
Are they solid/well formed?
 *
Does your stool float or sink? *
Do you see bits of undigested food (not including corn, but like leafy greens or bits of carrot, etc.)?
 *
Are they lighter, earthy brown, or darker in color (or some other color)?
 *
Do you ever leave 'skid marks' in the bowl after you flush?
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Are they very smelly?
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Do you experience gas / bloating / indigestion / bad breath / diarrhea / acid reflux / sensitive stomach? Please describe.
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Do you have trouble falling asleep? Staying asleep? Falling back to sleep?
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Do you remember your dreams?
Do you practice sleep hygiene?
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About how many hours per night do you average? *
Do you or have you ever worked night shift/unconventional hours? *
Do you experience (check all that apply)
Do you experience pain? If so, where and how often? On a scale of 1 (mild) to 10 (extreme), what would you rate your level of pain? Please describe:
 *
On a scale of 1-10 (10 being high), what is your level of stress?
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Do you or have you ever worked around any chemicals such as herbicides/pesticides, welding, industrial chemicals, hair dyes, oil, fumes, metals, etc.? If so for how long?
 *
Have you ever lived, worked, or spent a good amount of time in a building that had mold, mildew, water stains, mustiness, leaks, or floods?
 *
How many times do you estimate you've been on antibiotics in your entire life? (Please elaborate, i.e. recurrent ear infections as a child, long duration for a Lyme protocol, UTI, parent that was quick to get them, etc.) *
Please describe any skin and/or nail issues (acne, rash, hives, jock itch, athlete's foot, toenail fungus):
Do you have any food sensitivities or allergies or are you allergic to anything?
 *
Do you eat a modified diet? 
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Are there any dietary plans you have tried and done well on, or had a poor experience with? Please describe. 
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Please describe the water you regularly drink (well, municipal, filtration processes, remineralization, etc.)
Tell me about your fitness routine if you have one. Do you work out (or walk, dance, etc.)? If so, how often and with what intensity and duration?
 *
Please describe your relationships with the people you are close to or see most often (tense, happy, etc.):
Do you like your job? *
Tell me about your dental history. *
Do you ever experience *
Do you have pets? Please describe. *
Do you or have you ever been a smoker of cigarettes or marijuana? *
How often do you drink alcohol (per week)? What type do you prefer? *
Do you have TMJ (jaw), spine, or neck discomfort?
 *
What is your ancestral heritage? (This will help with your genetic interpretation)
What supplements/medications are you currently taking? *
Are you currently utilizing any modalities? (sauna, foot baths, Epsom soaks, ozone, red light therapy, etc.) *
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