Client Intake Form

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– Step 1 of 9

Services *

Nourish & Thrive
Renew & Reset
Rest & Restore
Glow Naturally

Personal Information

Name *

Phone *

Age *

Preferred Communication Method *

Email
Phone
Text

Email *

Occupation

On average, how many hours do you work per week ?

What are your personal health goals ?

Hobbies / Activities

What would you like to gain from working together ?

Lifestyle and Wellness

Current Diet:

Exercise Routine:

Stress Management:

Dietary Restrictions:

Current Activity Level:

Current Stress Level (1 is low – 10 is highest)

Selected Value: 0

Typical Daily Nutrition:

Types of Exercise:

Stress Coping Mechanisms:

Mineral Testing Consent

Are you interested in comprehensive mineral analysis?

Previous mineral or hormone tests:

apply wake well

PCOS and Health Background

PCOS Diagnosis Date *

Current Health Provider

Gynecologist

Endocrinologist

Primary Care Physician

Do you sleep well ?

Do you wake up during the night ?

If Yes, what time?

What time do you usually go to bed and what time do you wake up ?

How much pure water do you drink per day in ounces ?

What do you experience often after meals:

gassy
bloating
tired

Do you drink caffeinated beverages ? (e.g. coffee, black tea soda, energy drinks etc.) if yes which one and how much ?

What were your eating habits like as a child ?

What symptoms do you experience regularly

constipation
craving sugar
craving salt
feeling extremely hungry

What percentage of your food is home cooked ?

How many days per week do you eat out ?

What kind of cookware do you usually use ( eg cast iron, Teflon, aluminum, stainless steel ?

What kind of fat do you usually cook with (butter, canola olive oil) ?

In your opinion, what do you think are the three healthiest foods you eat each week and why ?

Please choose all that apply regarding your cycle :

Period are sporadic
Age of first period
Flow is very light
Flow is very heavy
Endometriosis
Experience severe cramps
Have experienced 1 or more miscarriages
Premenopausal

Prior to getting pregnant, did you or your mother take birth control or use a copper UTI ?

Have you ever been vegan or vegetarian ? If so, for how long and when ?

Have you had your gallbladder removed ?

What does your current exercise or movement routine consist of ? (days per week, length of time, type of exercise)

Please list all current vitamins, minerals, supplements, and /or prescription and over the counter medication you are taking regularly ?

Please list any known allergies ?

Are you currently under a doctor or practitioner’s care for a specific issue ?

Do you use water softener or have well water ?

Nutritional Assessment Questionnaire

Check all that apply (A)

Drink Alcohol ( Never / Monthly)
Artificial Sweeteners
Candy, Desserts, Refined Sugar
Carbonated beverage, include sparkling water
Chewing Tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Food
Luncheon Meats
Margarine
Radiation Exposure
Refined Flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control

Check all that apply (G)

Experience pain relief with aspi
Crave fatty or greasy foods
Low or reduced fat diet
Tension headache at base of skull
Headache when out in the sun
Sunburn easily or suffer sun poisoning
Muscle easily fatigued
Dry flake skin or dandruff

Check all that apply (H)

Awake a few hour after falling asleep, hard to get back to sleep
Crave sweets
Bings or unconditionally eating
Excessive appetite
Crave coffee and sugar in the afternoon
Sleep in the afternoon
Fatigue that is relieved by eating
Headache if meals are shipped or delayed
Irritable before meals
Shaky if meal delayed
Family members with diabetes
Frequent thirst
Frequent urination

Check all that apply (I)

Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in alms and legs
Enlarge heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart racing
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweat
Restless leg syndrome
Crack on corner of mouth
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and /or twnd to bruise easily
Bleeding gums especially when brushing teeth

Other Concerns:

Rest and Restore Assessment Questionnaire

Check all that apply (A)

Drink Alcohol ( Never / Monthly)
Artificial Sweeteners
Candy, Desserts, Refined Sugar
Carbonated beverage, include sparkling water
Chewing Tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Food
Luncheon Meats
Margarine
Radiation Exposure
Refined Flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control

Check all that apply (G)

Experience pain relief with aspi
Crave fatty or greasy foods
Low or reduced fat diet
Tension headache at base of skull
Headache when out in the sun
Sunburn easily or suffer sun poisoning
Muscle easily fatigued
Dry flake skin or dandruff

Check all that apply (H)

Awake a few hour after falling asleep, hard to get back to sleep
Crave sweets
Bings or unconditionally eating
Excessive appetite
Crave coffee and sugar in the afternoon
Sleep in the afternoon
Fatigue that is relieved by eating
Headache if meals are shipped or delayed
Irritable before meals
Shaky if meal delayed
Family members with diabetes
Frequent thirst
Frequent urination

Check all that apply (I)

Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in alms and legs
Enlarge heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart racing
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweat
Restless leg syndrome
Crack on corner of mouth
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and /or twnd to bruise easily
Bleeding gums especially when brushing teeth

Other Concerns:

Renew & Reset Assessment Questionnaire

Check all that apply (A)

Drink Alcohol ( Never / Monthly)
Artificial Sweeteners
Candy, Desserts, Refined Sugar
Carbonated beverage, include sparkling water
Chewing Tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Food
Luncheon Meats
Margarine
Radiation Exposure
Refined Flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control

Check all that apply (B)

Belching or Gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (NO-Never, YES-Monthly)
Bad Breath
Loss of Taste for Meat
Sweat has a strong odor
Stomach gets upset from taking vitamins
Sense of excess fullness after meals
Feel like skipping Breakfast
Feel Better if you don’t eat
Sleep after meals
Fingernails chip, peel or break easily
Anemia unresponsive to iron
Stomach pains or cramps
Diarrhea, chronic
Diarrhea shortly after meals
Black or Tarry colored stools
Undigested food in stool

Check all that apply (C)

Pain between shoulder blades
Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car or airplane motion sickness
Light or clay colored stools
Dry skin, itchy feet, or skin peels on feet
Headache over eyes
Gallbladder attacks
History of morning sickness
Bitter taste in mouth, especially after meals
Alcoholic drinks per week (non,1-3, 4-7, or 7+ )
Exposure to diesel fumes
Pain under right side of rib cage
Nutrasweet or Aspartame consumption (typically in diet drinks, diet products)
Chronic fatigue or Fibromyalgia
Gallbladder removed
Become sick if you were to drink wine
Easily intoxicated if you were to drink wine
Easily hungover if you were to drink wine
Recovering Alcoholic
History or drug or alcohol abuse
History of hepatitis
Long term use of prescription or recreational drugs
Sensitive to chemicals ( perfume, cleaning agents, ect)
Sensitive to tobacco smoke
Hemorrhoids or varicose veins

Check all that apply (D)

Food Allergies
Abdominal bloating 1 – 2 hours after eating
Specific food make you tired or bloated
Pulse speeds after ending
Airborne allergies
Experience hives
Sinus congestion.stuffy head
Crave bread or noodles
Alternating constipation and diarrhea
Crohn’s disease (No / Yes)
Wheat or grain sensitivity
Dairy sensitivity
Are these foods you could not give up? (No / Yes)
Asthma, sinus infections, stuffy nose
Bizarre, vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal

Check all that apply (E)

Anus itches
Coated tongue
Feel worse in moldy or musty place
Taken antibiotics for a total accumulated time of ( Never taken antibiotics, Less than 1 month, 1-2 months, 3 + months)
Fungus or Yeast infections
Nail Fungus
Yeast Symptoms increase with sugar, starch and alcohol ( Yeast symptoms: fatigue, poor memory, feeling spacey or unreal, muscle aches)
Stool hard or difficult to pass
History of Parasites
Less than one bowel movement a day
Stool have corners or edges, are flat, or ribbon shaped
Irritable bowel or mucus colitis
Blood in stool
Mucus in stool
Excessive foul smelling lower bowel gas
Bad breath or Strong Body Odors
Painful to press along the outer sides of the thighs
Cramping in lower abdominal region
Dark circles under the eye

Check all that apply (F)

History of carpal tunnel syndrome
History of lower right abdominal pains
History of stress fracture
Bone loss (reduced density on bone scan
Calf, foot, or toe cramps at rest
Clod sores, fever blisters, or herpes lesions
Frequent fevers
Frequent skin rashes and /or hives
Herniated disc
Excessively flexible joints double jointed
Joints pop or click
Pain or Swelling in joints
Bursitis or tendonitis
History of bone spurs
Morning Stiffness
Nausea with vomiting
Crave Chocolate
Feet have a strong odor
History of Anemia
White of eye are blue tinted
Hoarseness in voice
Difficulty swallowing
Lump in throat
Dry mouth, eye and/or nose
Dry mouth, eye and/or nose
Gag easily
White spots on fingernails
Cuts heal slowly and/or s ar easily
Decreased sense of taste or smell

Check all that apply (G)

Experience pain relief with aspi
Crave fatty or greasy foods
Low or reduced fat diet
Tension headache at base of skull
Headache when out in the sun
Sunburn easily or suffer sun poisoning
Muscle easily fatigued
Dry flake skin or dandruff

Check all that apply (H)

Awake a few hour after falling asleep, hard to get back to sleep
Crave sweets
Bings or unconditionally eating
Excessive appetite
Crave coffee and sugar in the afternoon
Sleep in the afternoon
Fatigue that is relieved by eating
Headache if meals are shipped or delayed
Irritable before meals
Shaky if meal delayed
Family members with diabetes
Frequent thirst
Frequent urination

Check all that apply (I)

Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in alms and legs
Enlarge heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart racing
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweat
Restless leg syndrome
Crack on corner of mouth
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and /or twnd to bruise easily
Bleeding gums especially when brushing teeth

Check all that apply (J)

Tend to be a night person
Difficulty falling asleep
Slow starter in the morning
Tend to be keyed up, trouble calming down
Blood pressure above 120/80
Headache after exercising
Feeling wired or jittery after drinking coffee
Clench or grind teeth
Calmon the outside, troubled on the inside
Chronic low back pain, worse with fatigue
Become dizzy when standing up suddenly
Difficulty maintaining manipulative correction
Pain after manipulative correction
Arthritic tendencies
Crave salty food
Perspire easily
Chronic fatigue, or drowsy often
Afternoon yawning
Afternoon Headache
Asthma, wheezing, or difficulty breathing
Pain on the medial or inner side if the knee
Tendency to sprain ankles or shiny splints
Tendency to need sunglasses
Allergies and /or hives
Weakness, dizziness

Check all that apply (K)

Height Over 6’6”
Early sexual development, before age 10
Increased libido
Splitting type Headaches
Memory falling
Tolerate sugar, feel fine when eating sugar
Height Under 4’ 10”
Decreased libido
Excessive thirst
Weight gain around hips or waist
Menstrual disorders
Delayed sexual development (after age 13)
Tendency to ulcers or colitis

Check all that apply (L)

Sensitive/allergic to iodine
Difficulty gaining weight, even with large appetite
Nervous, emotional, can’t work under pressure
Inward trembling
Flush easily
Fast pluse at rest
Intolerance to high temperatures
Difficulty losing weight
Mentally sluggish reduced initiative
Easily fatigued, sleeping during the day
Sensitive to cold, poor circulation (cold hands and feet)
Constipation, chronic
Excessive hair loss and/or coarse hair
Morning headaches, wear off during the day
Loss of lateral ⅓ of eyebrow
Seasonal sadness

Check all that apply (M)

Aware of heavy and/ or irregular breathing
Discomfort at high altitude
Air hunger or sigh frequently
Compelled to open windows in a closed room
Shortness of breath with moderate exertion
Ankles swell, especially at end of day
Cough at night
Blush or face turns red for no reason
Dull pain or Tightness in chest and/or radiate into right arm, worse with exertion
Muscle cramps with exertion

Check all that apply (N)

Pain in mid-back region
Puffy around the eye, dark circles under eyes
History of kidney stones
Cloudy, bloody, or darkened urine
Urine has a strong odor

Check all that apply (O)

Runny or drippy nose
Catch colds at the beginning of winter
Mucus producing cough
Frequent colds or flu
Other infections ( sinus, ear, lung, skin, bladder, kidney, ect)
Never get sick
Acne (Adult)
Itchy skin (dermatitis)
Cysts,boils rashes
History of Epstein -barr, Mono, Herpes, Shingles,Chronic fatigue syndrome, Hepatitis, or other Chronic viral condition

FAMALE ONLY (P)

Depression during per
Mood swings associated with periods (PMS)
Crave Chocolate around per
Breast tenderness associated with cycle
Excessive menstrual Flow
Scanty blood flow during periods
Occasional skipped period
Occasional skipped periods
Variations in menstrual cycle length
Endometriosis
Uterine fibroids
Breast fibroids, benign masses
Painful intercourse
Virginal Discharge
Virginal dryness
Virginal itching
Tendency to gain weight around hips, thighs and buttocks as supposed to others areas such as the mid section
Excess facial or body hair
Hot flashes
Night sweat

Other Concerns:

Glow Naturally Assessment Questionnaire

Check all that apply (A)

Drink Alcohol ( Never / Monthly)
Artificial Sweeteners
Candy, Desserts, Refined Sugar
Carbonated beverage, include sparkling water
Chewing Tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Food
Luncheon Meats
Margarine
Radiation Exposure
Refined Flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control

Check all that apply (B)

Belching or Gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (NO-Never, YES-Monthly)
Bad Breath
Loss of Taste for Meat
Sweat has a strong odor
Stomach gets upset from taking vitamins
Sense of excess fullness after meals
Feel like skipping Breakfast
Feel Better if you don’t eat
Sleep after meals
Fingernails chip, peel or break easily
Anemia unresponsive to iron
Stomach pains or cramps
Diarrhea, chronic
Diarrhea shortly after meals
Black or Tarry colored stools
Undigested food in stool

Check all that apply (C)

Pain between shoulder blades
Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car or airplane motion sickness
Light or clay colored stools
Dry skin, itchy feet, or skin peels on feet
Headache over eyes
Gallbladder attacks
History of morning sickness
Bitter taste in mouth, especially after meals
Alcoholic drinks per week (non,1-3, 4-7, or 7+ )
Exposure to diesel fumes
Pain under right side of rib cage
Nutrasweet or Aspartame consumption (typically in diet drinks, diet products)
Chronic fatigue or Fibromyalgia
Gallbladder removed
Become sick if you were to drink wine
Easily intoxicated if you were to drink wine
Easily hungover if you were to drink wine
Recovering Alcoholic
History or drug or alcohol abuse
History of hepatitis
Long term use of prescription or recreational drugs
Sensitive to chemicals ( perfume, cleaning agents, ect)
Sensitive to tobacco smoke
Hemorrhoids or varicose veins

Check all that apply (D)

Food Allergies
Abdominal bloating 1 – 2 hours after eating
Specific food make you tired or bloated
Pulse speeds after ending
Airborne allergies
Experience hives
Sinus congestion.stuffy head
Crave bread or noodles
Alternating constipation and diarrhea
Crohn’s disease (No / Yes)
Wheat or grain sensitivity
Dairy sensitivity
Are these foods you could not give up? (No / Yes)
Asthma, sinus infections, stuffy nose
Bizarre, vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal

Check all that apply (E)

Anus itches
Coated tongue
Feel worse in moldy or musty place
Taken antibiotics for a total accumulated time of ( Never taken antibiotics, Less than 1 month, 1-2 months, 3 + months)
Fungus or Yeast infections
Nail Fungus
Yeast Symptoms increase with sugar, starch and alcohol ( Yeast symptoms: fatigue, poor memory, feeling spacey or unreal, muscle aches)
Stool hard or difficult to pass
History of Parasites
Less than one bowel movement a day
Stool have corners or edges, are flat, or ribbon shaped
Irritable bowel or mucus colitis
Blood in stool
Mucus in stool
Excessive foul smelling lower bowel gas
Bad breath or Strong Body Odors
Painful to press along the outer sides of the thighs
Cramping in lower abdominal region
Dark circles under the eye

Check all that apply (F)

History of carpal tunnel syndrome
History of lower right abdominal pains
History of stress fracture
Bone loss (reduced density on bone scan
Calf, foot, or toe cramps at rest
Clod sores, fever blisters, or herpes lesions
Frequent fevers
Frequent skin rashes and /or hives
Herniated disc
Excessively flexible joints double jointed
Joints pop or click
Pain or Swelling in joints
Bursitis or tendonitis
History of bone spurs
Morning Stiffness
Nausea with vomiting
Crave Chocolate
Feet have a strong odor
History of Anemia
White of eye are blue tinted
Hoarseness in voice
Difficulty swallowing
Lump in throat
Dry mouth, eye and/or nose
Dry mouth, eye and/or nose
Gag easily
White spots on fingernails
Cuts heal slowly and/or s ar easily
Decreased sense of taste or smell

Check all that apply (G)

Experience pain relief with aspi
Crave fatty or greasy foods
Low or reduced fat diet
Tension headache at base of skull
Headache when out in the sun
Sunburn easily or suffer sun poisoning
Muscle easily fatigued
Dry flake skin or dandruff

Check all that apply (H)

Awake a few hour after falling asleep, hard to get back to sleep
Crave sweets
Bings or unconditionally eating
Excessive appetite
Crave coffee and sugar in the afternoon
Sleep in the afternoon
Fatigue that is relieved by eating
Headache if meals are shipped or delayed
Irritable before meals
Shaky if meal delayed
Family members with diabetes
Frequent thirst
Frequent urination

Check all that apply (I)

Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in alms and legs
Enlarge heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart racing
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweat
Restless leg syndrome
Crack on corner of mouth
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and /or twnd to bruise easily
Bleeding gums especially when brushing teeth

Check all that apply (J)

Tend to be a night person
Difficulty falling asleep
Slow starter in the morning
Tend to be keyed up, trouble calming down
Blood pressure above 120/80
Headache after exercising
Feeling wired or jittery after drinking coffee
Clench or grind teeth
Calmon the outside, troubled on the inside
Chronic low back pain, worse with fatigue
Become dizzy when standing up suddenly
Difficulty maintaining manipulative correction
Pain after manipulative correction
Arthritic tendencies
Crave salty food
Perspire easily
Chronic fatigue, or drowsy often
Afternoon yawning
Afternoon Headache
Asthma, wheezing, or difficulty breathing
Pain on the medial or inner side if the knee
Tendency to sprain ankles or shiny splints
Tendency to need sunglasses
Allergies and /or hives
Weakness, dizziness

Check all that apply (K)

Height Over 6’6”
Early sexual development, before age 10
Increased libido
Splitting type Headaches
Memory falling
Tolerate sugar, feel fine when eating sugar
Height Under 4’ 10”
Decreased libido
Excessive thirst
Weight gain around hips or waist
Menstrual disorders
Delayed sexual development (after age 13)
Tendency to ulcers or colitis

Check all that apply (L)

Sensitive/allergic to iodine
Difficulty gaining weight, even with large appetite
Nervous, emotional, can’t work under pressure
Inward trembling
Flush easily
Fast pluse at rest
Intolerance to high temperatures
Difficulty losing weight
Mentally sluggish reduced initiative
Easily fatigued, sleeping during the day
Sensitive to cold, poor circulation (cold hands and feet)
Constipation, chronic
Excessive hair loss and/or coarse hair
Morning headaches, wear off during the day
Loss of lateral ⅓ of eyebrow
Seasonal sadness

Check all that apply (M)

Aware of heavy and/ or irregular breathing
Discomfort at high altitude
Air hunger or sigh frequently
Compelled to open windows in a closed room
Shortness of breath with moderate exertion
Ankles swell, especially at end of day
Cough at night
Blush or face turns red for no reason
Dull pain or Tightness in chest and/or radiate into right arm, worse with exertion
Muscle cramps with exertion

Check all that apply (N)

Pain in mid-back region
Puffy around the eye, dark circles under eyes
History of kidney stones
Cloudy, bloody, or darkened urine
Urine has a strong odor

Check all that apply (O)

Runny or drippy nose
Catch colds at the beginning of winter
Mucus producing cough
Frequent colds or flu
Other infections ( sinus, ear, lung, skin, bladder, kidney, ect)
Never get sick
Acne (Adult)
Itchy skin (dermatitis)
Cysts,boils rashes
History of Epstein -barr, Mono, Herpes, Shingles,Chronic fatigue syndrome, Hepatitis, or other Chronic viral condition

FAMALE ONLY (P)

Depression during per
Mood swings associated with periods (PMS)
Crave Chocolate around per
Breast tenderness associated with cycle
Excessive menstrual Flow
Scanty blood flow during periods
Occasional skipped period
Occasional skipped periods
Variations in menstrual cycle length
Endometriosis
Uterine fibroids
Breast fibroids, benign masses
Painful intercourse
Virginal Discharge
Virginal dryness
Virginal itching
Tendency to gain weight around hips, thighs and buttocks as supposed to others areas such as the mid section
Excess facial or body hair
Hot flashes
Night sweat

Other Concerns:

Goals and Expectations

Primary Health Goals:

Specific Hair Health Objectives:

Expectations from the Coaching Program: