Health Intake
Name *
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Preferred name to be addressed as:
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How did you hear about Marshall: *
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Complete Mailing Address:
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Phone # (Primary) *
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Cell or other?
Phone # (secondary)
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Cell or other?
Email *
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Age *
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Gender
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Height *
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Weight *
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Date of Birth
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YYYY
Were you born via vaginal or cesarean delivery?
Were you breastfed
Where you grew-up, was there nearby industrial/conventional farming or animal feeding operations?:
Did you have any health problems as a child? :
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Did you receive antibiotics or other medications as a child?
Which part of the world did your ancestors ORIGINALLY come from, as in prior to living in the United States (unless they have Native American Ancestry):
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Are your parents and grandparents still living?
Did they or do they have any chronic health conditions?:
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Do you have any siblings?
If yes, are they being treated for any medical conditions?:
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Do you have pets? How many and what kind(s)?:
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Occupation:
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How many hours per week do you currently work?:
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Enjoy your work?:
Describe your work situation, does it require sitting often, staring at a computer, being in-doors, away from windows, being around a high amount of wifi or other electrical devices, chemicals, using antibacterials often? Please explain:
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Primary Sources of Stress?
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Do you take any particular steps to improve stress management? :
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Have supportive relationships in your pursuit of your health/performance goals?:
Have areas in your life where you find passion, purpose, meaning?
#1 health concern or performance goal (Please list them in order of importance to you): *
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#2 health concern or performance goal:
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#3 health concern or performance goal:
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Do you have any other particular issues that you are concerned about, whether they seem important now or not?:
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Have you recently worked with any other practitioners/trainers/coaches on these goals? If so, who?
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Are you currently being treated for any medical conditions?:
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Have you been diagnosed with any other conditions as an adult?:
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Do you exercise?:
What are your current training goals (if different than top 3 health goals above):
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What does a typical week of training/exercise look like? :
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How much do you move outside of formal exercise? :
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Shoes you usually exercise in?:
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Shoes you usually work in?:
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other shoes often worn?:
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Any additional orthopedics, inserts, etc?:
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Do you sleep well? :
How long do you sleep for on average?
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Do you take any particular steps to improve your sleep? :
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Spend time outside? If so, how much time/ how often on average?
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Time spent sitting per day?:
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What medications and supplements do you currently take?:
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What other medications and supplements have you regularly taken over the last year?:
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Vaccination history in lat 10 years (if any), which ones and when (approximately)?
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List any/all sensitivities and/or allergies:
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What does a typical day of food/drink look like? :
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Do you take a particular approach to your diet (types of diets, foods you avoid, etc)? :
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If so, why? :
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Do you eat out often?:
What percentage of your foods are organic, grown without chemicals, grass-fed or free-range?:
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What percentage of your food is bought fresh/unprocessed (i.e. unprocessed produce, unprocessed meats)?:
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Use alcoholic beverages?:
If so, how often/what type & quantity?:
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Do you use tobacco? If yes, what form and how often:
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Any history of addiction?:
Any other drug use?:
Do you carry a cell phone or other wireless device on your person regularly?:
If so, where do you carry your cell phone or other wireless device?:
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What kind of case for your device(s) if any?:
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List electrical devices active/known at your home/apartment (security systems, wifi, satellite, number of computers, wireless devices, etc):
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List items plugged-in and active wireless devices in bedroom at night:
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Do you use any devices/ways of protecting yourself from electromagnetic frequencies, radiation, etc?:
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List any treatments used on yard/garden on your property, as specifically as possible, even if apartment:
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List all household cleaners present in/around home/car (kitchen, bathroom, windows, etc) including brand:
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List all laundry cleaning/softener products used, including brands:
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List all body/beauty care products used, including brands and product name:
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Use a microwave?
Any and all known mold locations in home, however small:
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Rooms with carpet in home? New or old?:
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Are there nearby industrial/conventional farming or livestock operations?:
Nearby high-voltage power lines or other high concentration of electrical current?:
Additional Information:
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