INTAKE FORM
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Date *
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First Name *
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Las Name *
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How would you like to meet? *
Skype or Google Hangout Name
This will let me know how to contact you.
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Phone Number *
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Email *
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Address *
Street Address
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City *
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State *
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Zip Code *
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Country *
How did you find my services?
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Age *
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Gender *
Height *
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Current Weight *
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Ideal Weight *
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Family / Living Situation *
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Children *
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Occupation *
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Describe major health concerns in detail, including symptoms: *
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When did symptoms begin? *
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How have you dealt with concerns in the past? *
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Check any of the following that pertain to you *
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Family health history /similar problems? *
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Current medical status *
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What other health practitioners are you currently seeing? *
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List all current medications (including birth control) *
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List all current vitamins, herbs and/or supplements currently taking: *
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Time spent/lived abroad? When? *
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History of antibiotic use: *
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Any foods you avoid? Why? *
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Do you have food cravings? What do you crave? Anything you suspect you are sensitive to? *
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Bowel movement frequency *
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Bowel movement consistency *
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Bowel movement color *
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Do you drink coffee every day? If so, with what? *
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Describe your sleep patterns *
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Any major exposure to toxins? Do you have mercury fillings? *
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For women: describe your menses pattern. PMS? *
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Exercise/Recreation? *
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How do you handle stress? *
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Energy level *
worst
best
What are you your biggest obstacles, challenges and struggles you face with diet and lifestyle? *
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Any recent major life changes/losses? *
Your answer
Any additional information that you think may be helpful? *
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Envision exactly where you would like to be and how you would like feel. What does that look like? *
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PAYMENT
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acknowledgement & consent to receive services
In order to use my services, Maryland state law requires that you acknowledge receipt of the information provided in this form and that you initial it as acknowledgment.

"I have read and understand the above disclosure about the nutrition services offered by Keli L. Schumacher, CNHP; Maya Herbals. I understand that Keli L. Schumacher is not a licensed physician and that nutrition services are not licensed by the state."
By initialing below, you acknowledge that any dietary or supplemental suggestions made by Keli L. Schumacher are entirely nutritional in nature, and are not intended as the diagnosis, cure or treatment for any disease or ailment. You also acknowledge that your physician is your primary health care provider, and is responsible for supervising all changes in diet and nutrient intake that you make.

I will provide 24-hour notice if an appointment must be missed or pay for half the missed session.
Initial Below *
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