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Consultation Intake Form

 This is a lengthy questionnaire, please take your time and be as thorough as possible. 

Personal Data
Height *
Weight *
Date of Birth *
Sex *
Male
Female
Blood Type *
Eye Color *
Diet, Nutrition and General Health Practices
How much alcohol do you consume weekly? *
How much artificial sweetener do you consume weekly? *
How many dairy products do you consume weekly? *
How much turkey and chicken do you consume weekly? *
How much fruit do you consume weekly? *
How many whole grains do you consume weekly? *
How many caffeinated beverages do you consume weekly? *
How many fried foods do you consume weekly? *
How much pork and shellfish do you consume weekly? *
How much fish do you consume weekly? *
How many vegetables do you consume each week? *
How many sodas do you consume each week? *
How often do you eat fast food each week? *
How much red meat do you consume each week? *
How many salads do you consume each week? *
How many meals do you prepare and eat at home each week? *
What are your favorite foods or cravings? *
What time do you get up during the week? *
What time is breakfast, lunch and dinner during the week? *
Do you snack during the day and/or evening? *
How many ounces of water do you drink each day? *
What kind of water do you drink? *
How many hours of sleep do you get each night, on average? *
Describe your sleep. *
Do you sleep on silk or cotton sheets? *
Do you wake during the night? If so, how many times and when? *
Do you urinate during the night and if so, how many times? *
If waking at night, do you fall back to sleep right away or stay awake for a while? *
What time do you wake in the morning? *
Do you nap during the day? *
How often do you exercise each week and for how long? *
What do you do for exercise? *
Do you smoke? If yes, what kind and how much each week? *
Please list any allergies. *
Describe your energy level. *
How often do you eliminate your bowels? *
Describe your stress level. *
How many hours are in your work day? Do you work afternoons and/or evenings? *
Are you currently under a doctor's care for any condition? If so, please list who and why. *
Please list all names and medications you are currently taking, prescription and non-prescription. *
What other therapies have you tried? *
Please tell us your primary concern for you next scheduled appointment with Sharon. *
Surgeries and Complaints
Please list the approximate date and age you were if you've had the following surgeries: Tonsils, Appendix, D&C, Breast Lumps, Hysterectomy or any other type of surgery. *
Please check any of these that concern you. * *
Allergies
Abdominal Pain
Dizziness
Back Problems
Loss of Memory
Joint Pain
Headaches
Constipation
Cold Hands and/or Feet
Eczema/Psoriasis
Poor Digestion
Acne
Hearing Problems
Burping
Ear Aches
Irregular Bowels
Crave Sweets
Vision Problems
Hair Loss
Hemorrhoids
Hernia
Lack of Patience
Nagging Cough
Nervousness
Shortness of Breath
Temper Problems
Sore Throat
Sinus Problems
Tire Easily
Skin Problems
Trouble Sleeping
Varicose Veins
Muscle Aches
Childhood History
Please check all that apply. *
Asthma
Chicken Pox
Colds
Diptheria
Hay Fever/Allergies
Draining Ears
Tonsilitis
Measles
Pleurisy
Pneumonia
Scarlet Fever
Scoliosis
Tuberculosis
Typhoid
Whooping Cough
Gonorrhea
Hives
Additional Information
What time do you typically eat breakfast, lunch and dinner? *
Do you eat while sitting down in a peaceful environment? If not, describe what mealtime is like for you. *
Do you chew your food well? *
Do you drink liquids with your meal? *
Are you more satisfied when you eat a meal with grains and vegetables or protein and vegetables? *
Do you crave sweets? *
How much sugar, brown sugar, maple syrup or honey do you consume each day? *
When do you eat sweets and what is your sweet of choice? *
Do you dry brush prior to showering? *
Do you brush your teeth after meals and snacks? *
Do you use a natural toothpaste? *
Do you floss your teeth? *
Do you have any silver mercury fillings in your teeth? *
Have you been exposed to any heavy chemicals in your life, either at work or elsewhere? *
Do you clean with chemicals at home? *
Do you wear clothing made from natural fibers? *
If you work, what is your job? Are you happy with your job, the people and the environment? *
If you are in a relationship or married, are you happy in the relationship? *
Do you have any pets? If so, what are they? Do you enjoy your pets? *
Do you belong to any support groups, social groups or participate in activities with friends? *
What do you do for fun? *
What brings you the. most joy in life? *
Are you more similar to your mother or father's side of the family? What makes you say so?
Women Only
Have you ever been on the pill? If so, how long?
Ovarian problems? Please describe if so.
Any uterine issues? Describe if so.
Menopause? Yes, no, length of time?
Do you suffer from PMS?
Are you taking hormone replacements?
Please share any other issues/concerns.
Men Only
Average urinary frequency per day?
Any dribbling?
Do you have leg pains?
Do you have insomnia?
Do you have any prostate trouble? If so, please explain.
Please share any other concerns.
First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last 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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
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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