Intake Form CONFIDENTIAL Welcome to my practice! Please fill out this intake form, and use as much detail as necessary. Name* First Last Email* Date of Birth Date Format: MM slash DD slash YYYY Best number to reach you*Referred By:*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 DarussalamBulgariaBurkina 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 What is your occupation?*What is your Blood Type, if known?*What is your height and weight?*Are you satisfied with your weight/body composition? If not, what is your goal weight?*Please list your top 3 health concerns:*How have you dealt with these concerns in the past? Did you find success with these approaches?*When did you first notice these concerns?*Have you ever been diagnosed with any illness or disease?*Are you currently working with other practitioners to resolve your health concerns?*Please list all diagnostic testing & lab work you've completed within the past year.*What are your health goals?*Is your family/spouse supportive of your goals?*How long has it been since you felt really good?*Do you exercise? Type & frequency*Do you engage in any stress reduction? Meditation? Yoga?*Are you happy in your life right now? What are your main sources of stress?*Living situation? Do you have children?*How do you deal with your stressors?*What do you do for fun?*Rate energy level on a scale from 1 (low) to 10 (high).*12345678910Are there times during the day you feel best? Worst?*How much sleep do you get each night, on average?*Do you wake up throughout the night? How often?*How much water do you drink per day?*Do you drink coffee? Tea?*Do you drink alcohol? How much per week?DigestionDo you have a bowel movement each day? If not, how often?*Do you have nausea?*YesNoSometimesDo you have abdominal/intestinal pain?*YesNoSometimesDo you have bloating?*YesNoSometimesDo you get bloated after meals?*YesNoSometimesDo you have heartburn?*YesNoSometimesAre you prone to diarrhea?*YesNoAre you prone to constipation?*YesNoDo you have gas?*YesNoAre your stools compact or hard to pass?*YesNoDo you belch frequently?*YesNoDo your bowel movements alternate between constipation and diarrhea?*YesNoAre you prone to yeast infections or fungal infections?*YesNoHave you had a bad bout of food poisoning within the past 5 years?*YesNoHormones (Women Only)Age you began menstruating:Do you have regular cycles? How many days between cycles?*How many days of bleeding?*Have you used/do you currently use hormonal birth control? What type(s)?*Do you/have you experienced low libido?*HistoryPlace of Birth*Ancestry*Family history of disease*Please describe your eating habits growing up.*Childhood illnesses:*How is your dental health? How many fillings do you have?*How many silver amalgam fillings?*Do you have seasonal allergies?*Any known food allergies or sensitivities?*List current medications you're taking:*Past medications:*How often have you taken antibiotics as a child/teen/adult?*DietList all vitamin/mineral supplements you're taking:*Describe your diet at the onset of your health issues.*Has your diet changed in response to health issues? (foods you can no longer tolerate, etc?)*What types of diet plans have you tried, if any? (Paleo, Weight Watchers, etc)*What are your favorite foods?*What foods are you currently avoiding, if any? And why?*Have you struggled with periods of binge eating, restriction, malnutrition, severe dieting?*Have you struggled with addiction to food, alcohol, drugs, tobacco, caffeine?*Describe your relationship with food.*Would you like a referral to an acupuncturist, chiropractor, therapist, massage therapist?*YesNoI'm not sureAnything else you'd like to add?*Client Agreement and Release* Please read the consent form below and check the box to agree.Mary Vance, NC offers the services of holistic nutrition: counseling on lifestyle and nutrition. I, the undersigned, agree that I am a voluntary participant in lifestyle and nutrition counseling sessions and programs offered by Mary Vance, NC and that I accept and pay for those services. I reserve the right to refuse participation or to withdraw at any time. I agree to provide at least 24 hours notice of any cancellation. Notice shall be given pursuant to email to email@example.com. If I do not give 24 hours notice, I understand that I will pay for the session in full. I understand the nutritional counseling services are designed to empower individuals to achieve their health goals and may include, but will not necessarily be limited to the following: • providing a lifestyle intervention to establish healthy eating habits • specific recommendations to support the body in improving specific health concerns • recommendations around exercise, rest, stress reduction • nutrition supplementation to support wellness • menu planning and daily journaling suggestions • work on self image and attitudes Mary Vance, NC is not a physician nor psychologist, and the scope of her consultation services does not include treatment or diagnosis of specific illnesses or disorders. If you, the client, suspect you may have an ailment or illness that may require medical attention, then you are encouraged to consult with a licensed physician without delay. Only a licensed physician can prescribe drugs. Any mention of drugs in the course of consultation is only for the purpose of providing a complete history of drugs that the client is taking and not for Mary Vance, NC to judge the appropriateness of the medication. Any change in prescription or dosage is a decision the client makes with his or her physician. The counseling/coaching offered under this Agreement is acknowledged and understood to be of a strictly non-medical nature. The services provided by Mary Vance, NC are at all times restricted to consultation on the subject of lifestyle and nutrition matters, intended for augmenting general health, and do not involve the diagnosing, prognosticating, treatment, or prescribing for treatment of disease. By checking the box above, you acknowledge that you understand that Mary Vance, NC is a health and nutrition consultant and not a physician. Mary Vance, NC will not be held liable for failure to diagnose or treat an illness, nor will she be liable for failure to prevent future illness.