Intake Forms

You have two options:

You can view and print the Intake Forms (PDF) to fill them out. The pediatric section near the end are only necessary for clients 12 and under.

Or, proceed to the online form below. Please complete in one sitting or you will lose the information and have to start again. It will take about 30 minutes depending on how much detail you need to provide.

Lifestyle Assessment Form (LAF 2018) – Giant Form

Name

Date

Age

Height

Weight

Purpose in seeking nutritional guidance

Main health concerns/complaints (in priority)

Major physical/emotional trauma in past five years?

Stress level (1 = low, 10 = high)

Financial

Career

Personal

Marriage

Health

Family

Spiritual

Unfulfilled expectations

Other (please elaborate)

How does your stress manifest itself?

Coping mechanisms

Exercise (type, frequency, time of day, duration)

Energy level (1–10)

Energy lulls/highs (time of day)

Average hours of sleep daily (incl. naps)

Bedtime

Awaken time

Occupation

Hours each day/week you work

Start/End work times

If yes: form, amount, duration

If yes: how much, how long

If yes: how often and type

If yes: Drug/Alcohol? How long ago?

How much?

When do you wish to reach your goal weight?

Main motivation to change your weight

Hours daily driving

Hours daily watching television

Hours daily reading

Hours daily in front of computer

Interests and hobbies

When was your last vacation?

List prescription meds & reasons

List OTC meds & reasons

Vitamins/minerals/herbals/homeopathics + dosages

If yes, how often?

If yes, list

Anaphylaxis (life-threatening) description

If yes, explain

If yes, reason

How often do you have a bowel movement?

Related to particular food/circumstances?

Allergies

Alzheimer’s

Asthma

Autoimmune disease (type)

Cancer (type)

Cardiovascular disease (type)

Cystic fibrosis

Hemochromatosis

Intestinal disease (type)

Kidney dysfunction

Liver/gall bladder disease (type)

Mental health disorder (type)

Obesity

Parkinson’s disease

Type 1 diabetes

Type 2 diabetes

Skin conditions (type)

If yes, describe

If yes, which trimester?

History of miscarriages?

If yes, please specify

PMS symptoms (specify)

If yes, specify

If yes, result

If yes, describe

Main meals per day

Times of day (meals)

Snacks per day

Times of day (snacks)

Weekly food budget

Food preparation skills (1–10)

If yes, explain

Fruit: Fresh/Dried/Canned (counts per day)

Vegetables: Cooked/Raw

Grains: Whole/Refined

Protein: Type + servings

Dairy Products: Type + servings

Other: Specify + servings

Breakfast

Lunch

Dinner

Snacks

Aluminum Pans (1–3)

Margarine (1–3)

Candy (1–3)

Microwave (1–3)

Fried Foods (1–3)

Fast Foods (1–3)

Luncheon Meats (1–3)

Cigarettes Item (1–3)

Artificial Sweeteners (1–3)

Refined Foods (1–3)

Tap water

Prepared vegetable juices

Coffee

Fresh vegetable juices

Tea

Red wine

Soft drinks (diet)

White wine

Soft drinks (regular)

Beer

Fresh fruit juices

Other alcoholic beverages

Fruit juices (prepared)

Bottled or spring water

Milk (1%, 2%, or whole)

Herbal tea

Favourite foods

How often do you eat them?

Foods craved

How often do you eat them?

If yes, why?

Explain

Primary symptom related to main health concern

Normal physiological function of affected area

How does the symptom affect you daily?

Positive changes resulting from this symptom/concern

Client Statement acknowledgement (type your name if agreeing)

Date

Signature (type full name)

Name

Address

City

Prov/State

Postal/ZIP

Home Phone

Work Phone

Mobile Phone

HOLISTIC HEALTH PRACTITIONER

Clinical nutritionist specialized in diet, supplement & bioenergetic medicine

Intake Forms

You have two options:

HOLISTIC HEALTH PRACTITIONER

Services

Bioenergetic Medicine

Metabolic Balance

Inflammatory Bowel Disease

Contact Us

(647) 720-6090

info@holisticityhub.com

1 Firvalley Ct, Toronto, On

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