Male Intake form

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Male Client Intake Form

Personal
Examinations
Habbits
Activity
Toxins
Diet Analysis
Family History
Ailments

This questionnaire is designed to provide me with all the information necessary to build you an individual nutritional program, specifically tailored to your needs. Please answer the questions as accurately as you can. Private and Confidential: All information is strictly confidential and will never be revealed to any third party without your consent.

Personal

First Name

Last Name

Patient Age

Work or Hobbies

List your health concerns in order of importance:

How does your greatest health concern limit you the most?:

How committed are you towards making valuable changes, on a scale of 1-10 (10 being highest)

If less than 10, what would you need to happen to take it up to a 10.

Weight

Height

Examinations

Have you had any of the Following: If yes give Reason, Dates and Amounts?

Hospital X-Rays:

MRI/Cat Scans:

Ultrasounds:

Last Dental Visit:

Dental Xrays:

Metal Fillings:

Last Eye Exam:

Vehicle Accidents (e.g. Whiplash):

Surgeries & Hospitalization Reasons & Dates:

Have you had any vaccinations? If yes give Reason, Dates and Amounts?

Habbits

Smoking: How many cigarettes do you smoke per day?

How many cups of Tea/Coffee do you drink per day?

How many units of alcohol do you drink per week?

Have you been addicted to Alcohol?

Have you had any treatment for alcohol addiction?

Have you taken any Recreational Drugs, if yes give details?

List all Prescription Medicines & Nutrient Supplement/Herbs that you are taking, including dosages:

Activity

What type of exercise?

How often do you exercise?

For how long?

Hobbies:

Sleep

How long per night?

If you wake up frequently at night what is the reason?

Nightmares:

Yes

Never

Past

Grind Teeth:

Yes

Never

Past

Wake Refreshed:

Yes

Never

Past

Snore:

Yes

Never

Past

Must nap during the day:

Yes

Never

Past

Sleep walk:

Yes

Never

Past

Social Life

Enjoy job:

Yes

Never

Past

Hours worked per week:

Active spiritual practice:

Yes

Never

Past

Stress involved with Significant relationship (1-10, 10 being most stress):

Toxin Exposure

Some description about this section

Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed to?

Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials?

Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing?

Are you particularly sensitive to perfumes, gasoline or other vapours?

Do you use pesticides, herbicides or other chemicals around your home?

Allergies

List all known Allergies (food, drugs, environment):

Do You Have any pets?

Diet Analysis

Please tick or circle the questions to which you would answer 'yes' or fill in the 'number of times' you eat the food referred to in the question.

Were you breast feed?

Was a significant percentage of your diet as a child high in fatty foods and sugar?

Do you go out of your way to avoid foods containing preservatives or additives?

Do you avoid foods, which contain sugar?

How many teaspoons of sugar do you add to food/drinks each day?

Do you use salt in your cooking?

Do you add salt to your food?

How many times a week do you have meals containing fried food?

How many packets of 'instant' or fast food do you eat each week?

How many times a week do you eat chocolate or confectionary?

What percentage of your diet is raw fruit and raw vegetables?

Do you wash fruit and vegetables before eating?

Do you normally eat white rice or flour?

How many cans of food do you eat per week?

How many slices of bread or rolls do you eat each week? How many pints of milk do you drink in a week?

How many times a week do you eat red meat? (beef, pork, lamb or game)

How many times a week do you eat white meat? (poultry, fish)

What is your usual alcoholic drink?

How many times a week do you eat live yoghurt?

Do you use a water filter or drink bottled water instead of tap water?

Do you frequently eat under stressful conditions or on the move?

How would you describe your appetite?

Sample Diet

Write down all the foods and drinks consumed over the last two days.

Please add as much information as possible including quantities eaten brand names, and whether the food is fresh or packaged, refined or natural.

DAY 1

Breakfast

Lunch

Dinner

Snacks/Drinks

DAY 2

Breakfast

Lunch

Dinner

Snacks/Drinks

Are these two days representative of your usual eating habits? If not, what is a more usual day?

Breakfast

Lunch

Dinner

Snacks/Drinks

Family History

Do you have any children? (If yes give details)

List any illnesses your children, brothers and sisters suffer/suffered from

How many brothers and sisters do you have? (If yes give details)

List any illnesses your mother suffers/suffered from

List any illnesses your father suffers/suffered from

How committed are you towards making valuable changes, on a scale of 1-10 (10 being highest)

If less than 10, what would you need to happen to take it up to a 10.

Additional Information

Ailments

Please select the appropriate option below.

(Y=Yes) if you currently have the problem,

(N=Never ) if you’ve never had the problem,

(P=Past) if you had the problem in the PAST.

Good Energy:

Yes

Never

Past

Fatigue:

Yes

Never

Past

If you have fatigue, when in morning, afternoon, evening is it the worst?

If you have fatigue, can you do what you need to during the day?

Yes

Skin

Rash:

Yes

Never

Past

Cancer:

Yes

Never

Past

Warts / Moles:

Yes

Never

Past

Hives:

Yes

Never

Past

Colour Change:

Yes

Never

Past

Perspiration:

Yes

Never

Past

Psoriasis/eczema:

Yes

Never

Past

Lump:

Yes

Never

Past

Dry:

Yes

Never

Past

Itchy:

Yes

Never

Past

Head

Headache:

Yes

Never

Past

Head Injury:

Yes

Never

Past

Dandruff:

Yes

Never

Past

Hair Loss:

Yes

Never

Past

Oily / Dry Hair:

Yes

Never

Past

Migraine:

Yes

Never

Past

Nose

Frequent Colds:

Yes

Never

Past

Post Nasal Drip:

Yes

Never

Past

Congestion:

Yes

Never

Past

Seasonal Allergies:

Yes

Never

Past

Polyps:

Yes

Never

Past

Nosebleeds:

Yes

Never

Past

Eyes

Dry/Watery:

Yes

Never

Past

Itchy:

Yes

Never

Past

Discharge:

Yes

Never

Past

Double Vision:

Yes

Never

Past

Blurry Vision:

Yes

Never

Past

Dark under Eyelids:

Yes

Never

Past

Glaucoma:

Yes

Never

Past

Cataracts:

Yes

Never

Past

Strain:

Yes

Never

Past

Styes:

Yes

Never

Past

Mouth / Throat

Canker sores:

Yes

Never

Past

Gum disease:

Yes

Never

Past

Root Canals

Yes

Never

Past

Sore Throat:

Yes

Never

Past

Cavities:

Yes

Never

Past

Hoarseness:

Yes

Never

Past

Dentures:

Yes

Never

Past

Dental Implants

Yes

Never

Past

Cold sores:

Yes

Never

Past

Loss of taste:

Yes

Never

Past

Neck

Stiffness:

Yes

Never

Past

Full movement:

Yes

Never

Past

Swollen Glands:

Yes

Never

Past

Tension:

Yes

Never

Past

Respiratory

Cough:

Yes

Never

Past

Wheezing:

Yes

Never

Past

Asthma:

Yes

Never

Past

Shortness of breath with exertion:

Yes

Never

Past

TB:

Yes

Never

Past

Painful breathing:

Yes

Never

Past

Shortness of breath sitting:

Yes

Never

Past

Bronchitis:

Yes

Never

Past

Shortness of breath lying down:

Yes

Never

Past

Pneumonia:

Yes

Never

Past

Cardiovascular

High Blood Pressure:

Yes

Never

Past

Rheumatic Fever:

Yes

Never

Past

Low Blood Pressure:

Yes

Never

Past

Murmurs:

Yes

Never

Past

Arrhythmias:

Yes

Never

Past

Palpitations:

Yes

Never

Past

Edema:

Yes

Never

Past

Chest Pain:

Yes

Never

Past

Urinary Tract

Incontinence:

Yes

Never

Past

Kidney Stones:

Yes

Never

Past

Frequent Infections:

Yes

Never

Past

Discharge/Blood:

Yes

Never

Past

Urgency:

Yes

Never

Past

Pain with Urination:

Yes

Never

Past

Gastrointestinal

Heartburn:

Yes

Never

Past

Vomiting:

Yes

Never

Past

Recent BM Change:

Yes

Never

Past

Liver Disease:

Yes

Never

Past

Indigestion:

Yes

Never

Past

Change in Appetite:

Yes

Never

Past

diarrhoea/Constipation:

Yes

Never

Past

Ulcer

Yes

Never

Past

Bloating:

Yes

Never

Past

Pancreatitis:

Yes

Never

Past

Hemorrhoids:

Yes

Never

Past

Nausea:

Yes

Never

Past

Bowel Movement Freq:

Yes

Never

Past

Gall Bladder Disease

Yes

Never

Past

Male

Testicular pain/swelling

Yes

Never

Past

Sexually Active

Yes

Never

Past

Hernia

Yes

Never

Past

S.T.D.

Yes

Never

Past

Discharge

Yes

Never

Past

Prostate Disease/Symptoms

Yes

Never

Past

Impotency

Yes

Never

Past

Musculoskeletal

Weakness:

Yes

Never

Past

Leg Cramps:

Yes

Never

Past

Stiffness:

Yes

Never

Past

Pain:

Yes

Never

Past

Tremors:

Yes

Never

Past

Arthritis:

Yes

Never

Past

Nervous

Paralysis:

Yes

Never

Past

Carpal tunnel syndrome:

Yes

Never

Past

Tingling/numbness:

Yes

Never

Past

Fainting:

Yes

Never

Past

Seizures:

Yes

Never

Past

Sciatica:

Yes

Never

Past

Mental / Emotional

Depression:

Yes

Never

Past

Anger/irritability:

Yes

Never

Past

Suicidal:

Yes

Never

Past

High-strung/tense:

Yes

Never

Past

Anxiety:

Yes

Never

Past

Fear/Panic

Yes

Never

Past

Eating disorder:

Yes

Never

Past

Psych Hospitalization:

Yes

Never

Past

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