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Intake form

Name *

First

Last

Phone Number

Email *

1. What is your chief complaint? *

2. How long has this been happening? *

3. How satisfied are you with your digestion? *

4. How satisfied are you with your weight? *

5. Do you ever have gas? How frequently, and what part of the day? *

6. Have you ever taken antibiotics? Which ones, how long, and when: *

7. Please describe your morning routine: *

8. Please describe your diet: *

9. Please list all supplements you are taking: *

10. Please list the ones that have helped, and for what: *

11. Please list any and all medications you have taken in your entire life: *

12. Please list any conventional medications you are currently taking: *

13. Please list any medical diagnosis: *

14. Please describe what types of doctors you are currently seeing: *

15. How often do you have appointments with them? *

16. How have they been able to help you? *

17. Do you have access to testing your bloodwork? *

18. What is your occupation? *

19. How many hours a week do you work? *

20. Do you like your job? *

21. Please describe any trauma that may have taken place in your life: *

22. Please describe your family life: *

23. Is there anyone in your life that you need to forgive? *

24. Describe your level of fear on a daily basis from 1-10. *