Intake Form Step 1 of 6 16% IntroductionDateDate of Birth/AgeNameHeightSexWeight BackgroundOccupation# of childrenHrs worked/dayAges of childrenDo you enjoy work?Marital Status Personal Health HistorySelect any/all that applyEating disorderCancerCurrently pregnant or breastfeedingDepression, anxiety or psychiatric careDiabetes/ HypoglycemiaFatigue or sleepinessFood or medication allergiesFood intolerance or sensitivitiesFrequent headaches/migrainesFrequent colds, runny nose or fluHeart disorder, attack, stroke, anginaHigh blood pressureAlcohol dependencyRecreational drug useJoint/back/muscular pain or injuryLow iron/anemiaLung disease/asthmaMenopauseOsteoporosis/Low bone densityProblems sleepingSurgeryThyroid problemsVegetarian/Vegan/Raw foodistOther medical issuesSilver-mercury fillingsHigh cholesterolFamily Health History (list family member)Food allergies/intoleranceHypoglycemiaDigestive issuesCancerHeart attacks, strokeObesity/OverweightHigh cholesterolLow iron/anemiaDiabetesOther medical issuesOther InformationWhat is your primary reason for coming here?What is your end goal?What is your main health concern or complaint?Have you experience any trauma or loss in the last 5 years?Medications (name, dose, what it's for)Vitamins, minerals, herbs, supplements (name, dose, what it’s for)Do you wish to gain weight or lose weight?Gain WeightLose WeightHow Much? FemalesAre you or could you be pregnant?YesNoAre you pre-menopausal or menopausal?YesNoAre you experiencing menopausal symptoms?YesNoIf yes, please specifyHave you had a bone density test?YesNoIf yes, please specify Dietary HabitsHave you followed a diet plan before? List program. Have you seen anyone regarding your nutrition before? Who?List the foods that you dislike and choose not to eatWhat are your favorite foods? How often do you eat them?What are your biggest nutrition challenges?How many times a day do you eat?Do you eat meals with:With FamilyOn The RunRestaurantFast FoodDo you feel there are restrictions to your diet due to the preferences of others? (yes/no) If yes, explainHow many ½ cup servings of each do you typically eat in a day?Fresh FruitDried FruitCanned FruitCooked VegetablesRaw VegetablesWhole Grains, please put the typeProtein, please put the typeDairy, please put the typeOther, please specifyDo you eat or use any of the following? (1 – rarely, 2 – regularly, 3 – often)Aluminum pansMicrowaveLuncheon MeatsAlcoholCigarettesCandyRefined FoodsFast FoodsNutraSweet/ aspartameMargarineFried FoodsCoffeeIndicate how many cups of the following you drink per day:Bottled or spring waterTap WaterFresh fruit juicesFruit juices (prepared)Fresh vegetable juicesFresh vegetable juicesSoft drinks (regular)Soft drinks (diet)Soft drinks (diet)BeerRed WineWhite WineOther AlcoholOtherCoffeeMilk 1% or 2%Milf (skim)TeaHerbal TeaHow often do you have a bowel movement?Do you strain to have a bowel movement?Related to particular foods or circumstances?Do you have loose bowel movements?Related to particular foods or circumstances?MealsWho does the grocery shopping in your house?Who does the cooking and food preparation in your house?Are there different diets in your household?How would you describe your cooking skill on a scale of 1-5 (1=minimal skill, 5=superb skill)Do you enjoy cooking?How much time do you have to devote to meal preparation and cooking/day? LifestyleDo you participate in any exercise programs? If yes, how long have you been exercising? How often?Do you vacation regularly?When was your last vacation?Do you participate in spiritual discipline? (religious group, meditation, church etc)YesNoWhat level of stress do you feel you are experiencing at this time?MinimalAverageConsiderableUnbearableWhat are the major causes of your stress? (check all that apply)FinancialCareerPersonalMarriageFamilySpiritualUnfulfilled expectationsHealthOtherIf other, please specifyHow does your stress manifest itself?Do you use any coping mechanism for your stress?What time do you go to sleep and wake up?How many hours do you sleep?Do you awaken feeling rested?YesNoHow many hours do you spend daily, on average:DrivingWatching TvReadingIn front of computerWhat are your interests and/or hobbies?How satisfied are you with: rank 1-5 (1=very dissatisfied, 5=very satisfied)Eating HabitsStress ManagementFitness and exercise habitsWeight/Body compositionSleep HabitsOverall HealthBody Image and self esteemEnergy levelsBowel Movements*Privacy Disclosure: All information collected for registration will be kept on file for identification and for Audra Bursae to contact the individual named. These files are confidential. Any new client seeking the services of Audra Bursae is required to fill in and sign this form before any services are performed. If the individual named below is sending a digital copy of this form, checking the checkbox next to the signature line is considered a digital signature. This form is to be filed and kept for insurance purposes Yes *Release: “I hereby release Audra Bursae and Nourish Mind + Body, LLC. from all claims of damages arising from any accident or injury which is caused by or arises from participation of the applicant named herein, during any program, any class or any therapy or any location where a program or therapy is held. I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being, and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.” Yes *Cancellation Policy: Once purchased, your packages and services with Nourish Mind + Body, LLC. are non-refundable. Please note that 24 hours notice must be given to cancel or rebook appointments. If 24 hours notice is not given, 100% of your consultation fee will be applied to the missed appointment. 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