Tipping Point Nutrition Client Intake Form
Name *
Address *
City / Province / Postal Code *
Best phone number to reach you *
Email *
How did you hear about us?
Age *
Birth Date *
MM
/
DD
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YYYY
Gender *
Height
Blood Type (if known)
Current Weight
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?
Family/Living Situation
Do you have children?
What is your occupation?
Exercise/Recreation – what activity, how often and for how long?
HISTORY
Have you lived or traveled outside of the country? If so, when and where?
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you had to take off from work or school in the last year?
Clear selection
HEALTH CONCERNS
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealt with these concerns in the past?
Clear selection
Have you experienced any success with these approaches?
What other health practitioners are you currently seeing? List name, and specialty below.
Please list the date and description of any surgical procedures you have had:
How often did you take antibiotics in infancy/childhood?
How often have you taken antibiotics as a teen?
How often have you taken antibiotics as an adult?
Were you breastfed as an infant? If so, for how long?
Were you born naturally or via C-section?
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Did you have any health issues as a child? (Chronic ear infections etc.)
List any medicine you are currently taking, including the brand name
List all vitamins, minerals, herbs and nutritional supplements you are now taking. Please include the brand and dosage information
Have any other family members had similar problems to what you are experiencing? If so, please describe
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:
Do you ever have symptoms of discomfort immediately after eating like bloating, gas, sneezing or hives? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain
Are there foods that you crave? If so, please explain:
Describe your diet at the onset of your health concerns
Do you have any known food allergies or sensitivities?
Which of the following foods do you consume regularly?
Are you currently on a special diet? If yes, which one
What percentage of your meals would you say are home-cooked?
Is there anything else we should know about your current diet, history or relationship to food?
Who primarily prepares the meals in your household?
Are there any foods you really like or dislike?
INTESTINAL STATUS
Bowel Movement Frequency
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If not every day, how many times a week would you say?
Bowel Movement Consistency
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Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
MEDICAL STATUS
Have you had any previous health conditions or are there conditions that you have a family history of?
HEALTH HAZARDS
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do scents seem to affect you?
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Are you or have you been exposed to second-hand smoke?
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Do you have mercury amalgam fillings?
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LIFESTYLE HISTORY
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
How do you handle stress?
Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?
SEXUAL HISTORY
Do you have any concerns or issues with your sexual functioning (pain with intercourse, dryness, libido issues, erectile dysfunction)?
Is there anything else about your sexual history that would be helpful to know?
MENTAL HEALTH STATUS
How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
Worst
Best
Clear selection
At what point in your life did you feel best? Why?
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.
Who in your family or on your health care team will be most supportive of you making dietary changes?
Please describe any other information you think would be useful in helping to address your health concern(s):
What are your overall health goals and aspirations?
FOR WOMEN ONLY
How are/were your menses? Do/did you have PMS? Painful periods: If so, explain.
In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Have you/do you still take birth control pills? If so, please list length of time and type.
Have you had any problems with conception or pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list here.
Any other comments/background that may be useful?
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