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LIfestyle Intake
BASIC INFO
First Name
Last Name
Today’s Date
Email Address
Mobile Phone
Birthdate
Street Address 1
Street Address 2
City
State
Zip Code
Biological Gender
Female
Male
Marital Status
Single
Married
Divorced
Widowed
Number of Children
INTERNAL & EXTERNAL STIMULI
What are the main reasons you are seeking our services today?
What is your frequency drinking coffee and tea?
What is your frequency with recreational drug use?
What is your frequency using tobacco?
What is your frequency drinking water?
What is your frequency drinking soda / pop?
Please list any medications you are currently taking.
Name, Reason, Duration
Please list any supplements you are currently taking.
Name, Reason, Duration
LIFE ASSESSMENT
How do you feel about your Significant Other?
Great
Good
Fair
Poor
Bad
How do you feel about your Family?
Great
Good
Fair
Poor
Bad
How do you feel about your Diet?
Great
Good
Fair
Poor
Bad
How do you feel about your Sex Life?
Great
Good
Fair
Poor
Bad
How do you feel about Yourself?
Great
Good
Fair
Poor
Bad
How do you feel about your Work?
Great
Good
Fair
Poor
Bad
How do you feel about your Spirituality?
Great
Good
Fair
Poor
Bad
How do you feel about your Exercise?
Great
Good
Fair
Poor
Bad
BODY CONDITIONS & ISSUES
How often do you experience issues with Excessive Appetite?
Frequently
Sometimes
Never
How often do you experience issues with Digestion?
Frequently
Sometimes
Never
How often do you experience issues with Heartburn / Reflux?
Frequently
Sometimes
Never
How often do you experience issues with Lower Back Pain?
Frequently
Sometimes
Never
How often do you experience issues with Insomnia?
Frequently
Sometimes
Never
How often do you experience issues with Laughing Without Reason?
Frequently
Sometimes
Never
How often do you experience issues with Sadness / Depression?
Frequently
Sometimes
Never
How often do you experience issues with Digesting Greasy Foods?
Frequently
Sometimes
Never
How often do you experience issues with Fatigue?
Frequently
Sometimes
Never
How often do you experience issues with Ear Ringing?
Frequently
Sometimes
Never
How often do you experience issues with Gallstones?
Frequently
Sometimes
Never
How often do you experience issues with Bitter Taste in your Mouth?
Frequently
Sometimes
Never
How often do you experience issues with Colitis / Diverticulitis?
Frequently
Sometimes
Never
How often do you experience issues with Usually Feeling Warm?
Frequently
Sometimes
Never
How often do you experience issues with Dizziness?
Frequently
Sometimes
Never
How often do you experience issues with Lack of Appetite?
Frequently
Sometimes
Never
How often do you experience issues with Vomiting?
Frequently
Sometimes
Never
How often do you experience issues with Bloating?
Frequently
Sometimes
Never
How often do you experience issues with Knee Problems / Pain?
Frequently
Sometimes
Never
How often do you experience issues with Palpitations?
Frequently
Sometimes
Never
How often do you experience issues with Chest Pains?
Frequently
Sometimes
Never
How often do you experience issues with Eye Problems?
Frequently
Sometimes
Never
How often do you experience issues with Cough / Coughing?
Frequently
Sometimes
Never
How often do you experience issues with Edema?
Frequently
Sometimes
Never
How often do you experience issues with Kidney Stones?
Frequently
Sometimes
Never
How often do you experience issues with Soft / Brittle Nails?
Frequently
Sometimes
Never
How often do you experience issues with Difficulty Making Decisions?
Frequently
Sometimes
Never
How often do you experience issues with Constipation?
Frequently
Sometimes
Never
How often do you experience issues with Usually Feeling Cold?
Frequently
Sometimes
Never
How often do you experience issues with Obsessed with Work and Personal Relationships?
Frequently
Sometimes
Never
How often do you experience issues with Loose Stool / Dirrhea?
Frequently
Sometimes
Never
How often do you experience issues with Belching / Burping?
Frequently
Sometimes
Never
How often do you experience issues with Nasal / Nose Problems?
Frequently
Sometimes
Never
How often do you experience issues with Hearing Impairment?
Frequently
Sometimes
Never
How often do you experience issues with Cold Hands / Feet?
Frequently
Sometimes
Never
How often do you experience issues with Hearing Impairment?
Frequently
Sometimes
Never
How often do you experience issues with Poor Memory?
Frequently
Sometimes
Never
How often do you experience issues with Jaundice?
Frequently
Sometimes
Never
How often do you experience issues with Shortness of Breath?
Frequently
Sometimes
Never
How often do you experience issues with Asthma?
Frequently
Sometimes
Never
How often do you experience issues with Decreased Sex Drive?
Frequently
Sometimes
Never
How often do you experience issues with Anger / Easily Angered?
Frequently
Sometimes
Never
How often do you experience issues with High Cholesterol?
Frequently
Sometimes
Never
How often do you experience issues with Depression?
Frequently
Sometimes
Never
How often do you experience issues with Anxiety?
Frequently
Sometimes
Never
How often do you experience issues with Headaches?
Frequently
Sometimes
Never
How often do you experience issues with Claustrophobia?
Frequently
Sometimes
Never
How often do you experience issues with Skin Problems?
Frequently
Sometimes
Never
How often do you experience issues with Bruising Easily?
Frequently
Sometimes
Never
How often do you experience issues with Nightmares?
Frequently
Sometimes
Never
How often do you experience issues with Vivid Dreams?
Frequently
Sometimes
Never
How often do you experience issues with Decreased Sense of Smell?
Frequently
Sometimes
Never
How often do you experience issues with Dental Problems?
Frequently
Sometimes
Never
How often do you experience issues with Hair Loss?
Frequently
Sometimes
Never
How often do you experience issues with Urinary Problems?
Frequently
Sometimes
Never
How often do you experience issues with Frequent Sickness / Easily Sick?
Frequently
Sometimes
Never
How often do you experience issues with Bloody Stool / Hemmorrhoids?
Frequently
Sometimes
Never
How often do you experience issues with Light or Clay Colored Stool?
Frequently
Sometimes
Never
BIOLOGICAL FEMALES
Age of Menarche
First Period
Numbers of Days in Cycle
Color of Flow
Number of Days of Flow
Clots?
Yes
No
Are you Pregnant?
Yes
No
Number of Pregnancies
Number of Abortions
Have you ever been diagnosed with Fibroids?
Yes
No
Have you ever been diagnosed with Fibrocystic Breasts?
Yes
No
Have you ever been diagnosed with HPV?
Yes
No
Have you ever been diagnosed with Endometriosis?
Yes
No
Have you ever been diagnosed with Pelvic Inflammatory Disease (PID)?
Yes
No
Have you ever been diagnosed with Ovarian Cysts?
Yes
No
Is Cramping associated with your menstrual cycle?
Yes
No
Is Stabbing Pain associated with your menstrual cycle?
Yes
No
Are Headaches associated with your menstrual cycle?
Yes
No
Are Mood Changes associated with your menstrual cycle?
Yes
No
Is Nausea associated with your menstrual cycle?
Yes
No
Is Increased Appetite associated with your menstrual cycle?
Yes
No
Are Hot Flashes associated with your menstrual cycle?
Yes
No
Is Discharge associated with your menstrual cycle?
Yes
No
Date of your last Gynecologic Exam
Date of your last Mammogram
Date of your last Pap Smear
Results of your last Pap Smear
Age of Menopause
Last Period
Do you wake at night to Urinate?
Yes
No
If you wake to Urinate, how many times per night?
Is there anything else you would like to explain regarding your condition?
BIOLOGICAL MALES
Date of your last Prostate Exam
Do you experience Dribbling Urine?
Yes
No
Do you experience Testicular Pain?
Yes
No
Do you experience Incontinence?
Yes
No
Do you experience Decreased Libido?
Yes
No
Do you experience Groin Pain?
Yes
No
Do you experience Delayed Stream?
Yes
No
Do you experience Something Other?
Yes
No
Do you wake at night to Urinate?
Yes
No
If you wake to Urinate, how many times per night?
Is there anything else you would like to explain regarding your condition?
Submit
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