Intake Form IMPORTANT 1. Please fast for 3 hours prior to your appointment. No food or drink except water. 2. Please hydrate as much as possible. Drink at least 3 glasses of water before your appointment, and void your bladder as necessary. Name* First Last Date of birth:* Date Format: MM slash DD slash YYYY Age:Sex:Phone*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country How did you find out about us?*Email Yes, I would like to receive "5 to Thrive" monthly wellness tips & motivation via email! Marital status:SingleMarriedDivorcedWidowedNumber of children:Emergency contact name:Relationship:Emergency Contact Phone:Blood typeABABOnot sureList paternal family diseases:List maternal family diseases:List any food or environmental allergies:What type of exercise do you do?How often and duration?Do you have a bowel movement every day?YesNoHow many per day?Do you experience digestive difficulties (bloating, constipation, gas, etc)?Health HistoryDescribe any health issues/problems you are currently experiencing and specify your main concern:*Describe any surgeries you have had. Include the year the surgery was performed.Describe all diagnoses given by your Physician(s) and the date each diagnosis was given.*If you have never been given a diagnosis, please type "none".List all supplementation (vitamins, minerals, herbs) you are taking:List all prescription medication you are taking and why you are taking it:Diet# of coffees per day:For how many years?If you quit, how long ago?# of carbonated beverages per dayAny diet drinks?For how many years?If you quit, how long ago?Do you consume alcoholYesNoHow many drinks per week?Estimate how much water you drink each daySource:How many servings of fruit and vegetables do you eat per day?Are the fruits and vegetables organic?Provide any other information that may be relevant, but hasn’t been covered in regard to diet:StressOn a scale of 1 to 10, how stressed do you feel?12345678910Briefly describe any stressful situations in you life right now:How often do you take time for yourself?What does this look like to you?Ie. time alone, time in nature, reading, tv, sports, working out, laying down, shopping, creative pursuits, hobbies, spa treatments etc. How many hours of sleep do you get each night?Do you wake up feeling rested?RadiationsHow many hours do you use a computer each day?How many hours do you use a cell phone or tablet each day?Are you exposed to fluorescent lights at work or home?YesNoHow often do you travel by plane?When was the last time?How often do you use a microwave oven?ChemicalsWhere did you live while growing up?CityRuralSuburbsWhat is your occupation?What type of environment do you work in?OfficeFactoryAre you exposed to chemicals at work?YesNoName them:Any tattoos?YesNoHow many cigarettes do you smoke per day?For how many years?If you quit, how long ago?How many dental fillings do you have?Have you had any removed?How many?Date of most recent removal: Date Format: MM slash DD slash YYYY How many root canals do you have?Date of most recent: Date Format: MM slash DD slash YYYY Do you use conventional or natural deodorant?Do you use antacids?YesNoAre you, or have you ever, taken birth control pills?YesNoFor how long?If you quit, how long ago?On a scale of 1 to 10, how intensely do you experience PMS?12345678910Have you ever had shots of vaccinations (including flu shot)YesNoWhich ones?How long ago?What drugs have you taken during your life, recreational or prescribed (in addition to the ones you are currently taking, listed above):Have you ever been on antibiotics?YesNoHow often?For what reasons?Date of last prescriptionHave you ever lived near any farms or large agricultural projects?YesNoWhat kind (dairy, vegetable, orchard, greenhouse)?When?Any renovations in your home within past 12 months?YesNoList cosmetics/makeup/toiletries you use regularly. Specify if natural.List household cleaning products that you are exposed to. Specify if natural.Which of the following best describes the type of recommendations that you are open to? Check all that apply. Nutritional & diet changes Supplements Lifestyle changes Referrals to alternative wellness practitioners Referrals to conventional health care practitioners Which of the following best describes your expectations and level of commitment to see a change in your health?I am fully ready for a change. I am looking for a detailed plan.I would like some suggestions or a general plan.I am here for information only.OtherWhich of the following best describes your expectations and level of commitment to see a change in your health?Is there anything that could get in the way of following a nutritional and lifestyle plan in order to achieve results?CommentsThis field is for validation purposes and should be left unchanged.