Adult Intake FormPlease set aside 10-15 minutes to fill out the form below.This form is important to gain detailed information about your current health.Note: this page DOES NOT autosave, please submit the form before exiting the tab. Name * First Name Last Name Email * Birthday * MM DD YYYY Phone * Country (###) ### #### Do you have children? * Yes No What are you doing for your health presently? * Choose all that apply Exercise Supplements Diet Prescription Doctor What do you feel may be the underlying factors contributing to your present health concerns? * Height * Weight * (in lbs.) Do you wish to gain weight or lose weight, and if so, how much? * Do you suffer from high or low blood pressure? If so, please explain. * What level of stress do you feel you are experiencing at this time in your life? * Minimal Average Considerable Unbearable What are the major causes or factors of your stress? Choose all that apply Financial Career Personal Marriage Health Family Spiritual Other Do you wake feeling rested? * Yes No Sometimes Describe your energy level? * How many hours a day do you work? * What type of work do you do? * Do you enjoy your work? * How many hours each day do you spend driving? * Describe what you do for exercise. * How many hours daily do you: Watch television? Read? Spend in front of the computer? * What are your interests/hobbes? * When was your last vacation? * MEDICAL HISTORY Are you currently taking any medication(s)? If so, please list medication(s) and reason(s). * Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosage. * Do you have any allergies or food intolerances? If yes, please list. * Have you ever been diagnosed with an illness or hospitalized? Explain. * How often do you have a bowel movement? * Do you strain to have a bowel movement? * FAMILY HISTORY Hereditary Diseases: Please indicate “F” for Father, “M” for Mother, “S” sibling, “G” Grandparent Heart Disease Diabetes Allergies Hypertension Arthritis Mental illness Cancer Osteoporosis Intestinal disease/Digestive Issues Other (please list) Have you ever been treated for drug and/or alcohol dependency? * Yes No DIETARY HABITS Describe what you eat on a typical day and what time you eat? Breakfast * Lunch * Dinner * Snacks * At what time do you have your FIRST and LAST meal or snack of the day? * What are your favorite foods? How often do you eat them, and what foods do you crave, if any? * Do you experience any symptoms if meals are missed? Explain. * Do you avoid certain foods? If so, what are they and why do you avoid them? * Do you experience any symptoms after meals? Explain. * SYMPTOMS Rate the following symptoms ( 1-3 ) depending on the severity experienced. Please leave blank if a symptom does not apply. 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or occurring often. The Digestive System Underactive Stomach 1. Undigested food in stool 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Stomach bloated after eating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Feeling tired or fatigue after eating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Eat when rushed or in a hurry 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heavy feeling and sleepy after eating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nausea after taking supplements 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Acne 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Overactive Stomach 2. Stomach pain 1 hour after eating or in the evening 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Burning sensation in stomach 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain aggravated by worry/tension 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hiatal Hernia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gastritis or Gastric Ulcer 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Acidic sensation in abdominal area 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heartburn, Indigestion 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Blood in stool 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in lower back 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Long term Aspirin use 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Liver 3. Yellow fingernails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Oily nose and/or forehead 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fats/greasy food causes nausea, headaches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Vertical white streaks on fingernails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Onions, cabbage, radishes or cucumbers cause gas and bloating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bad breath, bad taste in mouth 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry, itchy or watery eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excess body odor 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) High cholesterol/High cholesterol diet 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Stiff, aching muscles 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Migraine headaches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Discomfort under right rib cage 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Food allergies 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irritable, easily angered 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Weight gain around the abdomen 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Yellow palms 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Jaundice 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Poor concentration 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Difficulty losing weight 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Acne, boils, rashes, psoriasis or eczema 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pancreas 4. Severe abdominal pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nausea and vomiting 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Slow digestion, feel full hours after eating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fever 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Alcohol addiction 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Jaundice 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Blood Sugar 5. Hungry up to 3 hours after eating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Strong, sudden cravings for sweets & starches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Strong, sudden cravings for coffee or colas 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent “midnight snacks” 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Family history of Diabetes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent headaches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fainting spells 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Depression 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Lose temper easily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gallbladder 6. Gallstones, history of gallstones 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Stool appears clay-coloured, foul odored 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Constipation 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) High cholesterol diet 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in right upper abdomen 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) High blood cholesterol levels 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) The Intestinal System & The Lymphatic/Immune System Candidiasis 7. Extreme fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Recurrent vaginal infections 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent antibiotic use 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) White coated tongue or oral thrush 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Crave sugar, bread, alcohol or colas 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Headaches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Tonsillitis, recurrent strep throat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Itchy, watery or dry eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Skin flushes, redness or rash 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Chronic indigestion and/or antacid use 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Always cold, particularly in the extremities 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) PMS 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in the pelvic area 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Abdominal gas and bloating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of sex drive 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cystitis, repeated bladder infections 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Increasing food and chemical sensitivities- severe reaction to tobacco, perfume etc 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Endometriosis, Ovarian cysts or issues 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Chronic diarrhea 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hives, psoriasis, acne, skin rashes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Rectal itching 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Abnormal muscle aches from exercise 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excess wax in ears 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Unexplained/Unexpected weight gain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Impotence 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cancer 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Athlete’s foot, finger/toenail fungus 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Parasites 8. Forgetfulness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Slow reflexes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gas and bloating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Unclear thinking 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of appetite 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Yellowish or pale face 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fast heartbeat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heart pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in navel 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Eating more than normal but still feeling hungry 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Blurry or unclear vision 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in back, thighs or shoulders 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Numb hands 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Drooling while asleep 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Damp lips at night 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry lips during the day 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Grinding teeth while asleep 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bed wetting 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Lethargy, chronic fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry circles under eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cancer 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Thymus (Immunity) 9. Excessive sleep 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Susceptible to infections 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Swollen glands in tonsils, throat or armpit 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) History of cancer, MS, arthritis, Parkinson’s etc. 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of appetite 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) The Lymphatic/Immune System & The Glandular/Endocrine System Allergies 10. Acne, psoriasis, dermatitis, eczema 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Rapid pulse, heart irregularities 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent headaches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hay fever, seasonal allergies 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent cravings for certain foods 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Periods of blurred vision 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Repeated ear trouble 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hyperactivity 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dizzy spells 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Periods of confusion 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Poor concentration 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Epilepsy 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle cramps or spasms 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excessive sweating, night sweats 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bowel disease: IBS, IBD, Crohn’s Disease 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Joint pain or stiffness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent night urination 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Wheezing 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pale face 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hives 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Runny nose 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gas or bloating after meals 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cold or mouth sores 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dark circles under eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Stuffy nose 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Blood in stool 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Lower back pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Stiff spine 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Mood swings, irritability 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dark circles under eyes or puffy eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Severe fatigue after eating certain foods 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Sinus congestion, pain or infection 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hypoglycemia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Thyroid 11. Tired, sluggish or lethargic 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cold hands and feet 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nodules on thyroid - past or present 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Mercury amalgams (fillings) 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gain weight easily, fail to lose on diets 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Constipation, less than 1 bowel movement daily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Low energy in the morning 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Low blood pressure 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Low body temperature 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry, brittle, dull or lifeless hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry, flaky or rough skin 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Feeling stiff after sitting for sometime 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Moods swings 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Unusually square and wide fingernails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) High cholesterol 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Low sex drive 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) PMS 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Weight loss without trying 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heart races while at rest 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Feel warm/flushed at room temperature 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hands shake or tremble 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Protruding tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heart palpitations 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nervous behaviour, hyperactivity 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Insomnia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Increased appetite 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent bowel movements, diarrhea 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excessive sweating 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pituitary 12. Infertility or impotence 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Headaches affecting 1 side 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Monthly cycle (period) gone 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Moody 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Overweight from the waist down 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Overweight from the waist up 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excessive urination 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in little finger of left hand 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Swelling in ankles, fingers or feet 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cold hands or feet 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in left side of upper neck 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) The Glandular/Endocrine System & The Structural/Muscular/Skeletal System The Adrenals 13. Emotional upsets or stress cause exhaustion 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Blood pressure decreases when going from a lying down position to a standing position 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Perspire excessively 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Neck or shoulder tension 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent headaches 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Brow lines 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cold sweats 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Panic or anxiety attacks 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Tightness or lump in throat, especially when emotionally disturbed 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) High or low blood pressure 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Rapid pulse 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Short temper 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Puffy face 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Skeletal 14. Pain, swelling or stiffness in joints 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscles weak, weak grip, light objects feel heavy to lift 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain, stiffness, inflammation of the spine 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Facial pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Joints make sounds like crinkling cellophane 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Joints make popping sounds 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gout 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Joint inflammation, rheumatoid Arthritis 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cramps in calf muscle during sleep, exercise or otherwise 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Painful cramping of feet or toes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Malformation of bones 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Insomnia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heart palpitations 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Diet high in saturated fat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bone fracture easily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gradual loss of height 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Lack of exercise 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Rounding of shoulders 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Menopause 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in forearm or bicep 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Neuromuscular 15. Muscle wasting in some part of the body 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Numbness or loss of sensation 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Mood swings or depression 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Blurred or double vision 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of balance or coordination 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Tingling or numbness, especially in extremities 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscular stiffness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Impotence 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Tremors 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of peripheral vision 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Slurred speech 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Sleep walking or bed wetting 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Objects fall from hands, reach in wrong place 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hands tremble 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Difficulty breathing 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscular 16. Muscle pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle strains 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Tendonitis 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle(s) spasm 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Informed Client Consent: I understand and agree that services performed by a Registered Holistic Nutritionist are not designed to cure any disease, deformity or mental/physical condition of any kind. The services performed are at all times restricted to consultation on the subject of nutrition and lifestyle intended for building wellness and do not involve the diagnosing, prognosticating or treatment of any illness requiring a medical license. As Nutritionists we make recommendations regarding diet, lifestyle and supplements to facilitate physical and spiritual health as RHN professionals. I am advised to consult with my family physician to confirm if any specific supplementation or recommendations will interfere with any medication I am currently taking or any medical condition I am currently being treated for. I understand that it is important to disclose any conditions or medications that I am currently taking. * I agree to the terms of service. Thank you for submitting the Adult Intake Form. BACK TO ALL FORMS
