Tipping Point Nutrition Client Intake Form
Name
Your answer
Address
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City / Province / Postal Code
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Best phone number to reach you
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Email
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How did you hear about us?
Your answer
Age
Your answer
Birth Date
MM
/
DD
/
YYYY
Gender
Your answer
Height
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Blood Type (if known)
Your answer
Current Weight
Your answer
CLIENT INTAKE
Thank you for taking the time to fill out this form and provide us with details of your health, goals and medical history. Be as detailed as possible, and use additional space if needed. Once you have answered all questions, please hit the SUBMIT button at the bottom of the page. Thank you!
What was your weight one year ago? Any major changes in your weight?
Your answer
Family/Living Situation
Your answer
Do you have children?
Your answer
What is your occupation?
Your answer
Exercise/Recreation – what activity, how often and for how long?
Your answer
HISTORY
Have you lived or traveled outside of the country? If so, when and where?
Your answer
Have you or your family recently experienced any major life changes? If so, please comment:
Your answer
Have you experienced any major losses in life? If so, please comment:
Your answer
How much time have you had to take off from work or school in the last year?
HEALTH CONCERNS
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
Your answer
When did you first experience these concerns?
Your answer
How have you dealt with these concerns in the past?
Have you experienced any success with these approaches?
Your answer
What other health practitioners are you currently seeing? List name, and specialty below.
Your answer
Please list the date and description of any surgical procedures you have had:
Your answer
How often did you take antibiotics in infancy/childhood?
Your answer
How often have you taken antibiotics as a teen?
Your answer
How often have you taken antibiotics as an adult?
Your answer
Were you breastfed as an infant? If so, for how long?
Your answer
Were you born naturally or via C-section?
Did you have any health issues as a child? (Chronic ear infections etc.)
Your answer
List any medicine you are currently taking, including the brand name
Your answer
List all vitamins, minerals, herbs and nutritional supplements you are now taking. Please include the brand and dosage information
Your answer
Have any other family members had similar problems to what you are experiencing? If so, please describe
Your answer
NUTRITIONAL STATUS
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom:
Your answer
Do you ever have symptoms of discomfort immediately after eating like bloating, gas, sneezing or hives? If so, please explain:
Your answer
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain
Your answer
Are there foods that you crave? If so, please explain:
Your answer
Describe your diet at the onset of your health concerns
Your answer
Do you have any known food allergies or sensitivities?
Your answer
Which of the following foods do you consume regularly?
Are you currently on a special diet? If yes, which one
Your answer
What percentage of your meals would you say are home-cooked?
Your answer
Is there anything else we should know about your current diet, history or relationship to food?
Your answer
Who primarily prepares the meals in your household?
Your answer
Are there any foods you really like or dislike?
Your answer
INTESTINAL STATUS
Bowel Movement Frequency
If not every day, how many times a week would you say?
Your answer
Bowel Movement Consistency
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Your answer
MEDICAL STATUS
Have you had any previous health conditions or are there conditions that you have a family history of?
Your answer
HEALTH HAZARDS
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Your answer
Do scents seem to affect you?
Are you or have you been exposed to second-hand smoke?
Do you have mercury amalgam fillings?
LIFESTYLE HISTORY
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
Your answer
How do you handle stress?
Your answer
Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?
Your answer
SEXUAL HISTORY
Do you have any concerns or issues with your sexual functioning (pain with intercourse, dryness, libido issues, erectile dysfunction)?
Your answer
Is there anything else about your sexual history that would be helpful to know?
Your answer
MENTAL HEALTH STATUS
How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger?
Your answer
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
Worst
Best
At what point in your life did you feel best? Why?
Your answer
OTHER
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Your answer
Who in your family or on your health care team will be most supportive of you making dietary changes?
Your answer
Please describe any other information you think would be useful in helping to address your health concern(s):
Your answer
What are your overall health goals and aspirations?
Your answer
FOR WOMEN ONLY
How are/were your menses? Do/did you have PMS? Painful periods: If so, explain.
Your answer
In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?
Your answer
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Your answer
Have you/do you still take birth control pills? If so, please list length of time and type.
Your answer
Have you had any problems with conception or pregnancy?
Your answer
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list here.
Your answer
Any other comments/background that may be useful?
Your answer
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