intake-form

Intake Form

The adult intake questionnaire below is a standard wellness client intake form used in Functional Medicine to get a more complete health history.

Accurately assessing all the factors and comprehensively managing them is the best way to understand your health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying root causes of illness and will also assist me in creating a treatment plan.

Name *

First

Last

Email *

Address *

City *

Province / State *

Postal Code / Zip Code *

Country *

Phone Number *

Time Zone *

Birth Date *

Age *

Place of Birth *

Height *

Weight *

Gender *

Today's Date *

Describe Problem(s) *

What treatments have you tried? *

Has anything been successful? *

With whom do you live? *

(Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister

Do you have any pets or farm animals? If yes, where do they live? *

Example: indoors/outdoors

Have you lived or traveled overseas? If so, when and where? *

Have you or your family recently experienced any major life changes? If yes, please comment:

Have you experienced any major losses in life? If so, please comment:

How much time have you lost from work or school in the past year?

Did you feel safe growing up? *

Have you been involved in abusive relationships in your life? *

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *

Do you feel safe, respected and valued in your current relationship? *

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *

Are you ok to talk about this during our work together? *

Please list any allergies or intolerances (to medications, food or environmental): *

List past Medical and Surgical History: *

List previous hospitalizations: *

How often have you taken antibiotics? *

(as a child and adult)

How often have you have taken oral steroids? *

(e.g., Cortisone, Prednisone, etc.)

What medications are you taking now? (including birth control/hormones) *

List all vitamins, minerals, and other nutritional supplements that you are taking now. *

Were you a full term baby? A preemie? Breast-fed or Bottle-fed? *

As a child did you eat a lot of sugar and/or candy? *

What is your typical daily diet: *

(List typical meals and snacks)

How much of the following do you consume each week? *

(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)

Are you on a special diet? *

Is there anything special about your diet that we should know? *

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? *

Do you feel much worse when you eat certain foods? *

Example: fat, protein, carbs, etc.

Do you feel much better when you eat certain foods? *

Example: fat, protein, carbs, etc.

Does skipping a meal greatly affect your symptoms? *

Have you ever had a food that you craved or really "binged" on over a period of time? *

Do you have an aversion to certain foods? If yes, what foods? *

How many bowel movements (BM) do you have per day? *

Example: 0-1, 1-2, 3 or more

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? *

Do you have intestinal gas? If so, when? *

How many times per week do you drink alcohol? *

Have you ever used recreational drugs?

Have you ever used tobacco? (If so, for how long?) *

Are you exposed to secondhand smoke regularly? *

Do you have mercury amalgam fillings in your teeth? If so, how many? *

Do you have any artificial joints or implants? If so, which ones? *

Do you feel worse at certain times of the year? *

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

Do odors affect you? If so, which ones?

How would you rate your current level of stress on a scale of 1-10? *

Women: If you have a cycle, how long is it and is it regular?

Women: Do you have any problematic symptoms related to your cycle?

Women: Any other comments related to your cycle? (flow, clots, mood changes, etc.)

Have you ever had psychotherapy or counselling?

List your hobbies and leisure activities: *

Do you exercise regularly? If so, how many times a week? *

What type of exercise is it?

Do you struggle with insomnia or interrupted sleep? *

Do your parents or siblings have (or had) any health issues? If so, please explain:

Please add any other information you feel is important:

Why do you believe you would be a good candidate to work with Melissa Deally? *

Congratulations, you are on the path to taking your first step towards health and wellness! *

I have read and understand everything on this page. I acknowledge Melissa Deally is a natural health practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Melissa Deally from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of her natural health services.

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“Let food be thy medicine and medicine be they food” ~ Hippocrates

intake-form

Intake Form

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