Happy Tummies of The Lowcountry, LLC
Please fill out the following to the best of your ability. If you do not know the answers to some of the questions or if you do not feel comfortable answering some of the questions, you can skip through them. The more information I have, the better I will be able to assess your case. All information exchanged herein is kept strictly confidential.
New Client Confidential Intake Form & Health History
Name: First and Last *
Your answer
Date *
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Address *
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Email Address *
Your answer
Phone *
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To protect your privacy, is it okay to leave a voicemail or message with someone other than yourself at this number? *
What is the best way to send personal health related information to you? *
Your answer
Your Age *
Your answer
Date of Birth *
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Place of Birth *
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Height *
Your answer
Weight *
Your answer
Would you like your weight to be different? If so what would be your goal weight? *
Your answer
Blood Pressure
Your answer
Blood Type
Your answer
Do you have any recent Blood Work or Labs that you would be willing to share? If yes, please email prior to, or bring with you to your appointment. This information can provide important clues as to your nutrition status. *
If you answered no to the above, would you like to add a General Wellness Blood Panel to your assessment for an additional $54? *
Were you born via natural birth or cesarean? *
Hobbies *
Your answer
Occupation
Your answer
How many hours per week do you work?
Your answer
Relationship Status *
Children? *
If yes, how many children & ages?
Your answer
What are your health concerns? *
Your answer
What would you like to accomplish or gain from this consultation? *
Your answer
Do you sleep well? *
Do you wake up during the night? *
Your answer
If so what time(s)? *
Your answer
What time do you go to bed? *
Your answer
What time do you usually wake up in the morning? *
Your answer
Do you feel well rested in the morning? *
Are you hungry in the morning? *
Your answer
Do you lack energy or feel tired throughout the day? *
Do you drink caffeinated drinks? If so what kind? *
Your answer
How much & often?
Your answer
Do you smoke or did you smoke in the past? *
If yes, how much & how often? When did you quit?
Your answer
Are you exposed to second hand smoke? *
If yes, how much and how long?
Your answer
Do you drink alcohol? *
How much & how often
Your answer
Do you crave alcohol?
How do you feel when you drink alcohol?
Do you drink soda? *
If yes, how much & how often?
Your answer
How much water do you drink per day? *
Your answer
What role does exercise play in your life? *
Your answer
What type of exercise do you do?
Your answer
Do you get easily fatigued with exercise? *
Did you play sports as a kid? *
Do you spend time outside? *
Are you exposed to known toxic substances at home or at work? Chemicals, fumes, mold etc... *
Do you wear antiperspirants? *
Are you aware of any water leaks, excess moisture or water damage in your home or workplace? *
Do you have any known allergies? *
Your answer
Do you get nose bleeds? *
Do you have a pet? *
Are you currently taking any vitamins, minerals, herbs, homeopathic remedies, laxatives, diet pills or any other supplements? *
If yes, please list
Your answer
Are you currently taking any prescription medications *
If yes, please list.
Your answer
Are you currently under a practitioner's care for any specific health issue. *
If yes, what treatments are you undergoing?
Your answer
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and date/age. *
Your answer
Are you aware of any chronic or viral presence such as Epstein Barr, Shingles, Cold Sores (Herpes), Chicken Pox, Warts (HPV) etc... *
Have you had any dental procedures done i.e.fillings, silver/mercury filling replacements, root canals, pulled teeth, crowns etc? *
Your answer
Have you had your gallbladder removed? *
What were your eating habits like as a child? Please list examples/types of foods. *
Your answer
Were you breast or bottle fed as an infant? *
Do you use a microwave to cook food? *
What percentage of your food is home cooked? *
Your answer
How often do you eat out? *
Your answer
What are the three worst foods you eat per week? *
Your answer
What are the three healthiest foods you eat per week? *
Your answer
What is your eating environment like? Do you sit while you eat? Eat with family/friends? Watch TV??? Stand in the kitchen? Eat in your car? *
Your answer
What type of pots and pans do you use? Non stick? Ceramic, Glass, Stainless Steal, Cast iron etc... *
Your answer
Are there certain foods that you eat every day? *
If you answered yes to the above, please list those specific foods that you eat "everyday"?
Your answer
Are there certain foods that cause obvious symptoms? *
If yes, please explain.
Your answer
Do you use any of the following in your food or cooking preparation? *
Required
Do you crave sugar? *
Do you crave salt? *
Do you experience diarrhea or constipation often? *
If yes, when and how often?
Your answer
Do you feel tired bloated or gassy after meals? *
What are your stools like? Hard, soft, sink, float, smelly? Light colored, Black? Don't be shy! *
Your answer
Have you ever had food poisoning? *
To your knowledge, have you ever had a bacterial, yeast or parasitic infection such as H. Pylori, Salmonella, C. Diff, Giardia, Candida, Lyme Disease, etc...? *
Do you feel excessively hungry? *
Do you have a poor appetite? *
Family History. Please check conditions experienced by your family members. *
Required
If yes to cancer, what type?
Your answer
Mother Age? *
Your answer
If deceased what was cause of death?
Your answer
Father Age? *
Your answer
If deceased what was cause of death?
Your answer
Maternal Grandmother Age? (Mother's side) *
Your answer
If deceased what was cause of death?
Your answer
Maternal Grandfather Age? (Mother's side) *
Your answer
If deceased what was cause of death?
Your answer
Maternal Grandmother Age? (Father's side) *
Your answer
If deceased what was cause of death?
Your answer
Maternal Grandfather Age? (Father's side) *
Your answer
If deceased what was cause of death?
Your answer
Are you close with your family members? *
Do you have excessive stress at home or at work? *
How would you measure your outlook on life on a scale of 1-10? Ten being the best. *
Please check the following that may apply to you: *
Required
Age of first period (Ladies only)
Your answer
Are your periods regular? If you are no longer menstruating, were your period regular when you were still menstruating?
How frequent?
Your answer
How many days is / was your flow?
Your answer
How heavy is / was your flow?
Your answer
Do / did you experience PMS?
If yes to PMS, is (was) it mild or severe?
What are (were) you PMS symptoms?
Your answer
Do you (or did you) ever notice other symptoms occurring more or less during different phases of your cycle? (An example would be like restless sleep prior to menstruation...or yeast infections after menstruation)
Your answer
Are you peri-menopausal?
When did this change first occur?
Your answer
Are you menopausal?
Do you feel your libido is adequate?
When was your last period?
Your answer
Do you take birth control now or have you taken birth control in the past?
Your answer
Do you, or have you had a copper IUD?
# of Pregnancies
Your answer
How many children have you delivered and were they born vaginally or cesarean?
Your answer
Were there complications with any of these pregnancies or deliveries?
Your answer
Did you receive antibiotics during labor
Have you ever had a miscarriage?
Males: Approximate Age of onset of puberty
Your answer
Males: # of Children
Your answer
Males: Do you feel your libido is adequate?
Males: Do you wake at night to urinate?
Males: If yes, how many times?
Your answer
Males: Do you have any difficulty or pain with urination?
Your answer
Males: Diminished volume of flow?
Males: Do you enjoy daily activities?
Males: Do you feel apathetic or complacent about previously enjoyed activities or hobbies?
Your answer
Ladies & Gents: Would you like to be added to Happy Tummies email list to receive periodic recipes and health related articles to your inbox? *
How did you hear about Happy Tummies Of The Lowcountry? *
Your answer
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