"Therapy Intake Form - Health Equations"

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health equation
I N TAKE FORM
Name
Date
Occupation
Age
Sex
D.O.B.
Blood Pressure
Pulse
Blood Type
Please circle words or check boxes for whatever applies to you; fill in blanks.
Water, Salt, Energy, Stress:
My current salt use is- l o w, moderate, heavy, by taste
Number of glasses of water each day _ _ _ _ _ _ _
I have never used much or any salt- Tru e or F a l s e
I crave salt and/or salty foods- Tru e or F a l s e
I previously used salt more than now- Tru e or F a l s e
I have unquenchable thirst-
Tru e or F a l s e
I have followed a low salt diet for _______ years.
I sweat ... a-lot, moderately, very little, not-at-all
Average energy level on a scale of 1 to 10 ______
Average stress level on a scale of 1 to 10 ______
Family History:
cardiovascular disease
adult onset diabetes
thyroid disease
o s t e o p o r o s i s
Milk Intolerance: (circle one) Y
N
Number of TOTAL pounds lost throughout your life dieting ________.
N u m b e r of silver/amalgam fillings, currently _ _ _ _ _ _ _ _ , removed _ _ _ _ _ _ _ _ .
N u m b e r of root canals, currently _ _ _ _ _ _ _ _ , removed _ _ _ _ _ _ _ _ .
E x p o s u re to heavy metals, chemicals, dust, infections, radiation, plastics:
___________________________
___________________________________________________________________________________
Women Only
Men Only
Number of childbirths ________
Prostate enlargement?
Y
N
Number of years nursing ________
Elevated PSA?
Y
N
Menstrual-related symptoms ______________________
Urination difficulties?
Y
N
______________________________________________
Perimenopausal years ________
Nighttime urination?
Y
N
Menopausal years ________
Sexual difficulties?
Y
N
Menopausal symptoms ___________________________
______________________________________________
s
health equation
I N TAKE FORM
Name
Date
Occupation
Age
Sex
D.O.B.
Blood Pressure
Pulse
Blood Type
Please circle words or check boxes for whatever applies to you; fill in blanks.
Water, Salt, Energy, Stress:
My current salt use is- l o w, moderate, heavy, by taste
Number of glasses of water each day _ _ _ _ _ _ _
I have never used much or any salt- Tru e or F a l s e
I crave salt and/or salty foods- Tru e or F a l s e
I previously used salt more than now- Tru e or F a l s e
I have unquenchable thirst-
Tru e or F a l s e
I have followed a low salt diet for _______ years.
I sweat ... a-lot, moderately, very little, not-at-all
Average energy level on a scale of 1 to 10 ______
Average stress level on a scale of 1 to 10 ______
Family History:
cardiovascular disease
adult onset diabetes
thyroid disease
o s t e o p o r o s i s
Milk Intolerance: (circle one) Y
N
Number of TOTAL pounds lost throughout your life dieting ________.
N u m b e r of silver/amalgam fillings, currently _ _ _ _ _ _ _ _ , removed _ _ _ _ _ _ _ _ .
N u m b e r of root canals, currently _ _ _ _ _ _ _ _ , removed _ _ _ _ _ _ _ _ .
E x p o s u re to heavy metals, chemicals, dust, infections, radiation, plastics:
___________________________
___________________________________________________________________________________
Women Only
Men Only
Number of childbirths ________
Prostate enlargement?
Y
N
Number of years nursing ________
Elevated PSA?
Y
N
Menstrual-related symptoms ______________________
Urination difficulties?
Y
N
______________________________________________
Perimenopausal years ________
Nighttime urination?
Y
N
Menopausal years ________
Sexual difficulties?
Y
N
Menopausal symptoms ___________________________
______________________________________________
s
health equation
Name
______________________________________
INTAKE FORM,
page 2
FOOD DIARY
DIGESTION INDICATO R
Please indicate the
you have of
NUMBER OF SERVINGS PER WEEK
C H E C K L I S T
each of the following foods:
food allergies/intolerances: ______
beef_______________
fresh fruit ___________________
____________________________
poultry
fresh vegetables _____________
white__________
crave specific foods: ___________
breads, cereals, grains and pastas:
dark___________
____________________________
~refined/processed__________
avoid specific foods: ___________
lamb_______________
~whole grain ______________
____________________________
fish________________
legumes________ seeds ________
low fat or no animal fat
n u t s / n u t b u t t e r s ______________
pork_______________
low or no carbohydrates
oils, please specify
weekly
burning sensation in stomach
soy “milk”__________
kind(s)
servings
which eating relieves
tofu/soy
______________________ _____
burping
products__________
______________________ _____
acid indigestion, sour stomach,
milk_______ %fat____
heartburn
______________________ _____
tight/full upper abdomen after eating
yogurt _____ %fat____
protein powder, specify kind - weekly
pale stools
cottage
_______________________ _____
cheese____ %fat____
crave fats
sweets (cookies, cakes, sodas,
gall bladder attacks or stones
eggs
______
(# per week)
c a n d y, ice cream, e t c .)__________
abdominal bloating / distention
butter______________
c a ffeine: tea______ coffee_______
flatulence (gas)
(sticks per week)
dark soda_____ light soda______
coated tongue
cheese _____________
wine_____ beer_____ liquor_____
(ounces per week)
diarrhea
constipation / incomplete evacuation
How much calcium do you supplement daily? ______ mg
alternating diarrhea and constipation
For how long? (circle one) weeks, months, years
loss of taste for meat
How much magnesium do you supplement daily? ______ mg
always hungry
For how long? (circle one) weeks, months, years
low blood sugar
high blood sugar
E X E R C I S E
SLEEP CHECKLIST
Please describe the type, frequency and duration of exercise.
Number of hours ________
____________________________________________________
Sleep quality:
____________________________________________________
poor
good
____________________________________________________
fair
excellent
awake during night at ______ a.m.
For Calculation of %BODY FAT
awake rested
difficulty falling asleep
H e i g h t ________
We i g h t ________
awake too early
Abdomen Measurement at Navel ________ inches
frequent snoring
( Women only) Hips Measurement at the Widest Point _______ inches
another person has witnessed you
stop breathing during sleep
(Men only) Wrist Measurement ________ inches
PLEASE INCLUDE A LIST OF ALL SUPPLEMENTS AND MEDICATIONS YOU ARE
CURRENTLY TAKING. BE SURE TO LIST THE DOSE AND FREQUENCY FOR EACH ONE.
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