All Information provided on intake forms all held in the strictest confidence and are used solely for the purpose of Wellness/Health Coaching and Therapeutic Massage and Skin Care.

 Information You Provide To Me.

The Website provides various places for users to provide information. I collect information that users provide by filling out forms on the Website, communicating with me via contact forms, responding to surveys, search queries on our search feature, providing comments or other feedback, and providing information when ordering a product or service via the Website.

I use the information you provide to me to deliver the requested product and/or service, to improve my overall performance, and to provide you with offers, promotions, and information.

Email Information

If you choose to correspond with me through email, I may retain the content of your email messages together with your email address and our responses. I provide the same protections for these electronic communications that I employ in the maintenance of information received online, mail, and telephone. This also applies when you register for my website, sign up through any of my forms using your email address or make a purchase on this site. For further information see the email policies below.

Email Policies

I am committed to keeping your e-mail address confidential. I do not sell, rent, or lease our subscription lists to third parties, and will not disclose your email address to any third parties except as allowed in the section titled Disclosure of Your Information.

I will maintain the information you send via e-mail in accordance with applicable federal law.

In compliance with the CAN-SPAM Act, all e-mails sent from My organization will clearly state who the e-mail is from and provide clear information on how to contact the sender. In addition, all e-mail messages will also contain concise information on how to remove yourself from my mailing list so that you receive no further e-mail communication from me.

My emails provide users the opportunity to opt-out of receiving communications from me and my partners by reading the unsubscribe instructions located at the bottom of any e-mail they receive from me at anytime.

Users who no longer wish to receive my newsletter or promotional materials may opt-out of receiving these communications by clicking on the unsubscribe link in the e-mail.

 

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This Intake is to help me better assist you in reaching your goals for wellness and health.  Please answer each question/statement honestly.


Review Linda Harris, CHC Privacy Policy

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.

 

Date Signed: September 30, 2020

Please select who will be participating...
AdultMinor
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First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Age *

Reason for visit (prioritized):


1. *

2.

3.

Nutritional data:


How many ounces of water/day?

What kind?

What other beverages and how much?
Do you use artificial sweeteners?*
No
Yes

If so, which ones?

How often and in what?
Do you eat breakfast?*
No
Yes

If so, what?

How much of the following do you consume? (example: 1D = 1/day, 2W = 2/week, 3M = 3/month)


Fresh fruit

Raw vegetables

Fermented foods

Fast foods

Meat

Eggs

Dairy

What do you crave?

What foods do you dislike the most?

Why?

Timing:


What is the first thing you do when you get up in the morning?

What time do you eat your first meal?

Last meal?

Which meal is your largest of the day?

Describe a typical largest meal.

Movement:


Do you exercise/move/participate in fun sweaty activity? If so, what and how often?

Do you look forward to it?

How do you feel when you are finished?

Sleep:


What 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?

Eliminations:


Do you have daily bowel eliminations?

If yes, how many per day?

If no, please describe your elimination pattern.

Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided.


BSC #

Color

Females:


Are you post-menopausal?

If yes, at what age did you enter menopause?

What were the characteristics of your menopausal experience?

Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?

Are you now, or in the near future, planning to become pregnant?

Is your menstrual cycle regular?

Longer than 28 days?

Shorter?

Is your flow longer or shorter than 5 days?

Do you have cramps or clotting?

Would you describe the color of your menses as bright red, dark purple, or brown?

Do you experience PMS, cyclical headaches, or cravings?

Supplements/medications:

Do you take any supplements?*
No
Yes

If so, what, how often and why?

Do you take any OTC medications routinely (such pain reliver or allergy medicine)? If so, what and how often?

Do you take prescription medications (prescribed by a licensed medical professional?) If so, what and how often?

Medical history:


Have you had any surgeries? If so, what and when?

Have you received any diagnoses from licensed medical professionals? If so, what and when?

Naturopathic history:


Have you ever been in consultation with a naturopath? If so, why? How long ago?

What was suggested?

Did you experience a good outcome?

What did you like about it?

What wasn't as successful for you?

Do you have regular adjustments with a chiropractor?

Do you have regular body work/massages?
Please check all with which you are familiar:
Homeopathy
Bach Flowers/flower remedies
Probiotics
Aromatherapy
Muscle response testing
Herbals
Sports nutrition
Enzymes
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age *

Reason for visit (prioritized):


1. *

2.

3.

Nutritional data:


How many ounces of water/day?

What kind?

What other beverages and how much?
Do you use artificial sweeteners?*
No
Yes

If so, which ones?

How often and in what?
Do you eat breakfast?*
No
Yes

If so, what?

How much of the following do you consume? (example: 1D = 1/day, 2W = 2/week, 3M = 3/month)


Fresh fruit

Raw vegetables

Fermented foods

Fast foods

Meat

Eggs

Dairy

What do you crave?

What foods do you dislike the most?

Why?

Timing:


What is the first thing you do when you get up in the morning?

What time do you eat your first meal?

Last meal?

Which meal is your largest of the day?

Describe a typical largest meal.

Movement:


Do you exercise/move/participate in fun sweaty activity? If so, what and how often?

Do you look forward to it?

How do you feel when you are finished?

Sleep:


What 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?

Eliminations:


Do you have daily bowel eliminations?

If yes, how many per day?

If no, please describe your elimination pattern.

Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool chart provided.


BSC #

Color

Females:


Are you post-menopausal?

If yes, at what age did you enter menopause?

What were the characteristics of your menopausal experience?

Do you currently use Hormone Replacement (HRT) or Hormonally-based Contraception?

Are you now, or in the near future, planning to become pregnant?

Is your menstrual cycle regular?

Longer than 28 days?

Shorter?

Is your flow longer or shorter than 5 days?

Do you have cramps or clotting?

Would you describe the color of your menses as bright red, dark purple, or brown?

Do you experience PMS, cyclical headaches, or cravings?

Supplements/medications:

Do you take any supplements?*
No
Yes

If so, what, how often and why?

Do you take any OTC medications routinely (such pain reliver or allergy medicine)? If so, what and how often?

Do you take prescription medications (prescribed by a licensed medical professional?) If so, what and how often?

Medical history:


Have you had any surgeries? If so, what and when?

Have you received any diagnoses from licensed medical professionals? If so, what and when?

Naturopathic history:


Have you ever been in consultation with a naturopath? If so, why? How long ago?

What was suggested?

Did you experience a good outcome?

What did you like about it?

What wasn't as successful for you?

Do you have regular adjustments with a chiropractor?

Do you have regular body work/massages?
Please check all with which you are familiar:
Homeopathy
Bach Flowers/flower remedies
Probiotics
Aromatherapy
Muscle response testing
Herbals
Sports nutrition
Enzymes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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