Intake Form

Customer Intake Form 2

Thank you for taking the time (10-15 minutes) to fill out this confidential form. (I know, I know, another form!) But this is an invaluable way for me to become familiar with and be more prepared for your needs at our appointment. Again, this is confidential and will never be discussed with anyone but you, including your family members (without your consent.) Again, thank you for taking your valuable time with this important information and I look forward to serving you!

Please do your best to be on time, as my schedule is very full! Also note, that traffic here is extremely unpredictable so please plan your travel time accordingly. Thank you!

General Information

Date(Required)

MM slash DD slash YYYY

(Required)

Male

Female

Name

First Last

Address

Street Address City State ZIP Code

Phone

Email(Required)

Age

Height

Weight

Birthdate

MM slash DD slash YYYY

# of Children

# of Grandchildren

Were you referred?

Yes

Who referred you? I would like to thank them!(Required)

What is your current occupation?

Do you work full-time or part-time?

Full

Part-time

Please send your most current blood work a few days prior to your appointment. You can upload below or you can email me with an attachment to Tammy@HolisticSolutions4u.com

Max. file size: 2 MB.

What are your expectations of me and my services?

In order to help me design testing specifically for you, have you had any vaccinations in the last five years?

Yes

Have you had a Covid vaccination / injection?

Yes

Which injection did you get?

Pfizer

Moderna

Johnson & Johnson

What is the approximate date(s) you received the vaccine / injection? Anything you would like to tell me about the experience?

Describe any additional vaccines you have received other than Covid19 Vaccines. (Please be specific about the type and dates of these vaccinations)

Approximately what dates/year did your current symptoms occur and what are they? (Please list the dates, as best you can next to each symptom).

What is your current stress level (0 = no stress 10 = extreme stress)

No stress

Extreme stress

Have you had any major surgeries, if so for what and what year?

Yes

Please describe your surgeries. Year of surgeries(s)?

What prescription medications are you currently taking?

When did you begin this medication(s)? What are the reason(s)?

Is it your goal to get off these medications?

Yes

Not sure

Are currently taking vitamins?

Yes

Current doctor or natural health practitioner? (MD, ND, Chiropractor, Acupuncture, etc.)

Have you ever seen a natural alternative practitioner before?

Yes

How long do you realistically think it will take for you to achieve your health goals?

What kind of diet do you follow now and is it your ideal diet or would you like to transition into something different?

Do you have any food allergies or environmental allergies?

Women only (Men press "Next" below)

Are you taking any prescription or natural hormones?

Yes

What are you taking? When did you start taking them?

Have you ever had symptoms of yeast infection vaginally?

Yes

Not sure

When or how long ago? How often has this occurred?

Have you gone through Menopause yet?

Yes

Currently going through menopause

Do you have regular menses? Are they heavy or light?

Have you ever had your hormones tested? When? What year?

Have you ever taken antibiotics?

Yes

If so, what year(s)?(Required)

Have you ever traveled outside of the US (including Mexico)?

Yes

What year(s) were you out of the country and what country(s) did you travel to?(Required)

Have you ever been tested for parasites (bugs)?

Yes

Not sure

Were your results positive or negative?

Positive

Negative

When and by what method were you tested? (blood test, feces or ?)

Have you ever been tested for Candida / Yeast?

Yes

Not sure

Were your results positive or negative?

Positive

Negative

When and by what method were you tested? (blood test, feces or ?)

Do you have any skin rashes or acne?

Rash

Acne

Both

Where are the rashes or acne on your body?

Have you ever been tested for heavy metal toxicity?

Yes

Not sure

Were your results positive or negative?

Positive

Negative

When and by what method were you tested? (blood test, feces or ?)

Have you ever had your vitamins and or minerals tested?

Yes

Not sure

When and by what method were they tested?

Have you ever done any type of body cleanse or detox?

Yes

Not sure

When did you do the cleanse? Please describe cleanse type and results.

Have you ever had Colon Hydrotherpy or have you done your own enema?

Yes

Not sure

Do you exercise regularly?

Yes

How often and what type of exercise?

How many glasses of water do you drink daily?

How many meals a day do you eat or are you a grazer?

4 or more

I graze throughout the day

How many bowel movements do you have daily?

3 or more

Do you have problems with constipation or loose bowels?

Constipation

Loose bowels

Both

Do you crave sweets or salty foods or both?

Sweets

Salty

Both

Do you now eat, or have you ever eaten raw fish?

Yes

When was the last time you consumed raw fish?

How often do you eat raw fish?

Do you have pets?

Yes

I've had pets in the past

Generally, what time do you get to sleep at night?

Do you have trouble falling asleep and or staying asleep? How long has this been occuring? (If so I'm sorry! UG!)

Is there anything else you would like to add? Also, if you have any blood work, please bring it with you if you can or email to me prior to your appointment.

Thank you for taking the time to fill out (another) form! I know this can be annoying, but it will help me help you! I am honored that you chose to contact me and I am looking forward to helping you reach your goals! I will be in contact with you soon....

Final note: Please bring any supplements you are currently taking along with any blood work to our initial appointment!