Men’s Intake Form First Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweAge *Phone *Email Address *Reason for visit: *Nutritional DataHow many ounces of water/day?What kind of water?What other beverages and how much?Do you use artificial sweeteners?YESNOIf you answered (YES) previously, What kind of sweeteners do you use?How often do you use artificial sweetener and in what?Do you eat breakfast?YESNOIf you answered (YES) previously, What do you eat for your breakfast?How many servings of fruit do you eat per week?How much fast foods do you eat per week?How many servings of vegetables do you eat per week?How much fermented foods do you eat per week?How many servings of meat do you eat per week?How many servings of eggs do you eat per week?How much dairy do you eat per week?What do you crave?What foods do you dislike the most?Why do you dislike the foods you mentioned previously?TimingWhat is the first thing you do when you get up in the morning?What time do you eat your first meal?What time do you eat your last meal?Which meal is your largest of the day?Describe a typical largest meal?MovementDo you exercise/move/participate in fun sweaty activity? If so, what and how often?Do you look forward to it?YESNOHow do you feel when you are finished?SleepWhat time do you go to bed?How long do you sleep?Do you wake often? If so, why and at what time(s)?Do you feel rested when you wake up for the day?Do you have pain when you first get up? If so, where?Does it go away upon moving?YESNOEliminationDo you have daily bowel eliminations?YESNOIf YES, how many per day?If no, please describe your elimination pattern.Supplements/medicationsDo you take any supplements?YESNOIf so, what, how often and why?Do you take any OTC medications routinely (such as Aleve or Aspirin)? If so what and how often?Do you take prescription medications (prescribed by a licensed medical professional?) If so what and how often?Medical historyHave you had any surgeries? If so, what and when?Have you received any diagnoses (including allergies) from a licensed medical professional? If so, what and when?Naturopathic historyHave you ever been in consultation with a naturopath? If so, why? How long ago?What was suggested?Did you experience a good outcome?YESNOWhat did you like about it?What wasn't as successful for you?Do you have regular adjustments with a chiropractor?YESNODo you have regular body work/massages?YESNOPlease check all with which you are familiar:HomeopathyBach Flowers/flower remediesProbioticsAromatherapyMuscle response testingHerbalsNutritionEnzymesConsent *I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease. Send Message
