Client Information Sheet

​

• Name ____________________________________________________________ Age ________

• Address _______________________________________________________________________

• Telephone (best) _____________________ Email _____________________________________

• Reason for visit (prioritized):

         1.______________________________________________________________________

         2.______________________________________________________________________

         3.______________________________________________________________________

 

Nutritional data:

• How many ounces of water per 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 of the following do you consume? (example: 1D = 1/day, 2W = 2/week, 3M = 3/month)

• Fruit _____ Vegetables _____ Eggs _____ Dairy _____ Fermented food _____ Fast food ___

• Chicken _____ Fish _____ Red Meat _____ Pork _____ Meat Alternatives _____

• 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 activities?

• 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 up 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

• bright red, dark purple, or brown? _________________________________________________

• Do you experience PMS, cyclical headaches, or cravings? _______________________________

 

​Supplements/medications:

• Do you take any supplements? ________ If so, what, how often and why? _________________

• ______________________________________________________________________________

• ______________________________________________________________________________

• Do you take any OTC medications routinely (such as pain relievers or allergy medicine)? 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? ____________________________________

• ______________________________________________________________________________

• Have you received any diagnoses from licensed medical professionals? 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 bodywork/massages? __________________________________________

 

Please check all with which you are familiar:

•  Homeopathy

•  Bach Flowers/flower remedies

•  Probiotics

•  Aromatherapy

•  Muscle response testing

•  Herbals

•  Sports Nutrition

•  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, and this is a personal ministry and spiritual

counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical

diagnostic purposes 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 ____________________

​

​

​