Intake by xiaopangnv

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									Introduction
                Date                                              Date of birth
               Name                                                    Height
                 Sex                                                   Weight
Background
      Occupation                                                  # of children
    Hrs worked/day                                             Ages of children
 Do you enjoy work                                               Marital status

Personal Health History
Select any/all that apply
                          Eating disorder                                   Recreational drug use
                                  Cancer                         Joint/back/muscular pain or injury
    Currently pregnant or breastfeeding                                           Low iron/anemia
 Depression, anxiety or psychiatric care                                     Lung disease/asthma
                 Diabetes/ Hypoglycemia                                               Menopause
                    Fatigue or sleepiness                          Osteoporosis/Low bone density
            Food or medication allergies                                        Problems sleeping
         Food intolerance or sensitivities                                                Surgery
         Frequent headaches/migraines                                            Thyroid problems
       Frequent colds, runny nose or flu                            Vegetarian/Vegan/Raw foodist
   Heart disorder, attack, stroke, angina                                    Other medical issues
                     High blood pressure                                     Silver-mercury fillings
                     Alcohol dependency                                           High cholesterol

Family Health History (list family member)
 Food allergies/intolerance                                      Hypoglycemia
          Digestive issues                                              Cancer
     Heart attacks, stroke                                 Obestity/Overweight
           High cholesterol                                    Low iron/anemia
                   Diabetes                                Other medical issues

Other Information
What is your primary reason for coming here today?



What is your end goal?

What is your main health concern or complaint?



Have you experienced 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?           Lose weight?                    How much? _____________________
FEMALES:
Are you or could you be pregnant?             Yes      No
Are you pre-menopausal or menopausal?         Yes      No
Are you experiencing menopausal symptoms?     Yes      No
If yes, please specify ___________________________________________________________________
Have you had a bone density test?             Yes      No
If yes, what was the result?_______________________________________________________________

Dietary Habits
Have 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 eat



What 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 family          Home alone          On the run        Restaurant        Fast food
Do you feel there are restrictions to your diet due to the preferences of others? (yes/no) If yes, explain


How many ½ cup servings of each do you typically eat in a day?
           Fruit:   Fresh        Dried        Canned
           Vegetables:      Cooked         Raw
           Whole grains: Type
           Protein: Type
           Dairy: Type
           Other: Specify


Do you eat or use any of the following? (1 – rarely, 2 – regularly, 3 – often)
  Aluminum pans                                      Cigarettes            NutraSweet/aspartame
      Microwave                                          Candy                        Margarine
 Luncheon meats                                   Refined foods                      Fried foods
         Alcohol                                     Fast foods                           Coffee
Indicate how many cups of the following you drink per day:
           Bottled or spring water              Tap water                  Milk (1% or 2%)
           Fresh fruit juices                   Beer                       Milk (skim)
           Fruit juices (prepared)              Red wine                   Tea
           Fresh vegetable juices               White wine                 Herbal tea
           Soft drinks (regular)                Other alcohol              Coffee
           Soft drinks (diet)                   Other
How 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?

Meals
Who 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? ______________________


Lifestyle
Do 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)



 What level of stress do you feel you are experiencing at this time?
 Minimal             Average             Considerable             Unbearable

 What are the major causes of your stress? (check all that apply)
 Financial         Career              Personal                   Marriage
 Family            Spiritual            Unfulfilled expectations           Health
 Other_____________________________________________________________________________
 How 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?
 Yes               No
 How many hours do you spend daily, on average:
 Driving _______        Watching TV _______          Reading _______         In front of computer _______
 What are your interests and/or hobbies?



How satisfied are you with: rank 1-5 (1=very dissatisfied, 5=very satisied)
                      Eating habits____________                    Stress management____________
        Fitness and exercise habits____________               Weight/Body composition____________
                      Sleep habits____________                           Overall health____________
      Body Image and self esteem____________                              Energy levels____________
                 Bowel movements____________



Privacy Disclosure: All information collected for registration will be kept on file for identification and for
Leanne Vogel to contact the individual named. These files are confidential. Any new client seeking the
services of Leanne Vogel 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.


Release: “I hereby release Leanne Vogel 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.”


Cancellation Policy: Once purchased, your packages and services with Healthful Pursuit 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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Signature:
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Address:
City, Province/State:                                      Postal/ZIP:
Phone (home):                                              Skype:
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