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 Today’s Date________________________________________

 Intake Form

Name___________________________________________________________  Age_________

Address_______________________________________________________________________

Telephone (best)_____________________Email_____________________________________

Reason for visit (prioritized):

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

Nutritional data:

How many ounces of water/day? _________ What kind?________________________________

What other beverages and how much? _____________________________________________

Do you use artificial sweeteners?_____  If so, which ones? _____________________________ How often and in what?_________________________________________________________

Do you eat breakfast? ________ If so, what?__________________________________________

How much per week of these:

Fresh fruit ___________Raw vegetables _____________Fermented foods _________________

Fast foods ___________Meat ______________________Eggs ___________________________

 Dairy ____________________

What do you crave? _______________________________________________________

What foods do you dislike the most? __________________________________________

Why? ___________________________________________________________________

________________________________________________________________________

Timing:

What is the first thing you do when you get up in the morning? ____________________

________________________________________________________________________

What time do you eat your first meal? ____________Last meal? ____________________

Which meal is your largest of the day? _________________________________________

Describe a typical “largest meal”______________________________________________
_________________________________________________________________________

Movement:

Do you exercise/move/participate in fun sweaty activity? If so, what and how often? ________________________________________________________________________________________________________________________________________________

Do you look forward to it? __________________________________________________

How do you feel when you are finished? _______________________________________

Sleep:

What time do you go to bed? _______________How long do you sleep?___________________

Do you wake often?_______ 

If so, why and at what time(s)?____________________________________________________

Do you feel rested when you wake up for the day? _______________________________

Do you have pain when you first get up?_______  If so, where?________________________ ____________________________________________________________________________

Does it go away upon moving?___________________________________________________

Eliminations:

Do you have daily bowel eliminations?______ If yes, how many per day?______________

If no, please describe your elimination pattern.________________________________________ ______________________________________________________________________________

Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided. BSC #_______________ Color _______________________________________

Females:

Are you post-menopausal?_____ _If yes, at what age did you enter menopause? ___________

What were the characteristics of your menopausal experience?_________________________

_____________________________________________________________________________

Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception? _____

Are you now, or in the near future, planning to become pregnant? __________________

Is your menstrual cycle regular?______ Longer than 28 days?______ Shorter? __________

Is your flow longer or shorter than 5 days? _____________________________________

Do you have cramps or clotting? ____Would you describe the color of your menses as more red, more purple, or more brown? _____________________________________________

Do you experience PMS, cyclical headaches, or cravings? __________________________

What kind of cravings do you have?

Supplements/medications:

Do you take any supplements? _______________  If so, what, how often and why?________________

__________________________________________________________________________

__________________________________________________________________________

Do you take any OTC medications routinely (such as Aleve or Aspirin)? If so what and how often? ____________________________________________________________________

Do you take prescription medications (prescribed by a licensed medical professional?) If so what and how often? _______________________________________________________

Medical history:

Have you had any surgeries? If so, what and when? ______________________________

________________________________________________________________________

Please list all…Have you received any diagnoses (including allergies) from a licensed medical professional? If so, what and when? _____________________________________________________________

______________________________________________________________________________

Naturopathic history:

Have you ever been in consultation with a naturopath? If so, why? How long ago? ________________________________________________________________________________________________________________________________________________

What was suggested? ______________________________________________________

Did you experience a good outcome? _________________________________________

What did you like about it? _________________________________________________

What wasn’t as successful for you? ___________________________________________

Do you have regular adjustments with a chiropractor? ____________________________

Do you have regular body work/massages? _____________________________________

Please check all with which you are familiar:

ð  Homeopathy

ð  Bach Flowers/flower remedies

ð  Probiotics

ð  Aromatherapy

ð  Muscle response testing

ð  Herbals

ð  Sports nutrition

ð  Enzymes

I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease.

Signature _____________________________________________Date ____________________

Bach Flower Self-Help Questionnaire  

Check all that apply. If you have to think about it, skip it. Don’t limit your choices.

Agrimony  

___I hide my feelings behind a facade of

cheerfulness

___I dislike arguments and often give in to avoid conflict

___I turn to food, work, alcohol, drugs, etc. when down

Aspen

___I feel anxious without knowing why

___I have a secret fear that something bad will happen

___I wake up feeling anxious

Beech

___I get annoyed by the habits of others

___I focus on others’ mistakes

___I am critical and intolerant

Centaury

___I often neglect my own needs to please

___I find it difficult to say “no”

___I tend to be easily influenced

Cerato

___I constantly second-guess myself

___I seek advice, mistrusting my own intuition

___I often change my mind out of confusion

Cherry Plum

___I’m afraid I might lose control of myself

___I have sudden fits of rage

___I feel like I’m going crazy

Chestnut Bud

___I make the same mistakes over and over

___I don’t learn from my experience 

___I keep repeating the same patterns

Chicory

___I need to be needed and want my loved ones close

___I feel unloved and unappreciated by my family

___I easily feel slighted and hurt

Clematis

___I often feel spacey and absent minded

___I find myself unable to concentrate for long

___I get drowsy and sleep more than necessary

Crab Apple

___I am overly concerned with cleanliness

___I feel unclean or physically unattractive

___I tend to obsess over little things

Elm

___I feel overwhelmed by my responsibilities

___I don’t cope well under pressure

___I have temporarily lost my self-confidence

Gentian

___I become discouraged with small setbacks

___I am easily disheartened when faced with difficulties

___I am often skeptical and pessimistic

Gorse

___I feel hopeless, and can’t see a way out

___I lack faith that things could get better in my  life

___I feel sullen and depressed

Heather

___I am obsessed with my own troubles

___I dislike being alone and I like to talk 

___I usually bring conversations back to myself

Holly

___I am suspicious of others

___I feel discontented and unhappy

___I am fully of jealousy, mistrust, or hate

Honeysuckle

___I’m often homesick for the “way it was”

___I think more about the past than the present

___I often think about what might have been

Hornbeam

___I often feel too tired to face the day ahead

___I feel mentally exhausted

___I tend to put things off

Impatiens

___I find it hard to wait for things

___I am impatient and irritable

___I prefer to work alone

Larch

___I lack self-confidence

___I feel inferior and often become discouraged

___I never expect anything but failure

Mimulus

___I am afraid of things such as spiders, illness, etc.

___I am shy, overly sensitive, and modest

___I get nervous and embarrassed

Mustard

___I get depressed without any reason

___I feel my moods swinging back and forth 

___I get gloomy feelings that come and go

Oak

___I tend to overwork and keep on in spite of exhaustion

___I have a strong sense of duty and never give up

___I neglect my own needs in order to complete a task

Olive

___I feel completely exhausted, physically, and/or mentally

___I am totally drained of all energy with no reserves left

___I’ve just been through a long period of illness or stress

Pine

___I feel unworthy and inferior

___I often feel guilty 

___I blame myself for everything that goes wrong

Red Chestnut

___I’m overly concerned and worried about my loved ones

___I’m distressed and disturbed by other people’s problems

___I worry that harm may come to those I love

Rock Rose

___I sometimes feel terror and panic

___I become helpless and frozen when afraid

___I often have nightmares

Rock Water

___I set high standards for myself

___I am strict with my health, work&/or spiritual discipline

___I am very self-disciplined, always striving for perfection

Scleranthus

___I find it difficult to make decisions

___I often change my opinions

___I have intense mood swings

Star of Bethlehem

___I feel devastated due to a recent shock

___I am withdrawn due to traumatic events in my life

___I have never recovered from loss or fright

Sweet Chestnut

___I feel extreme mental or emotional heartache

___I have reached the limits of my endurance

___I am in complete despair, all hope gone

Vervain

___I get high-strung and very intense

___I try to convince others of my way of thinking

___I am sensitive to injustice, almost fanatical

Vine

___I tend to take charge of projects, situations, etc.

___I consider myself a natural leader

___I am strong-willed, ambitious, and often bossy

Walnut

___I’m experiencing change in life-a move, new job, etc.

___I get drained by people or situations

___I want to be free to follow my own ambitions

Water Violet

___I give the impression that I’m aloof

___I prefer to be alone when overwhelmed

___I often don’t connect to with people

White Chestnut

___I am constantly thinking unwanted thoughts

___I repeatedly relive unhappy events or arguments 

___I’m unable to sleep at times because I can’t stop thinking

Wild Oat

___I can’t find my path in life

___I am drifting in life and lack direction

___I am ambitious but don’t know what to do

Wild Rose

___I am apathetic and resigned to whatever happens

___I have the attitude, “It doesn’t matter anyhow”

___I feel no joy in life

Willow

___I feel resentful and bitter

___I have difficulty forgiving and forgetting 

___I think life is unfair and have a “Poor me attitude”

Determining Your Custom Remedy

After completing the questionnaire, circle

the remedy names where two or more

checks appear to determine which remedies

are needed. Try to limit the number of

remedies to six or fewer by choosing 

only the ones that are needed.

pH Levels  

Sugars____________________

Urine pH__________________

Saliva pH__________________

Salts______________________

Cell Debris_________________

Nit Nit____________________

Amm Nit__________________

Total Ureas________________

Eye Photo

Nail Photo

Tongue Photo

Face Photo

MRT Points to check: