Health Intake Name * First Name Last Name Email * Phone * (###) ### #### What service are you interested in? * Premier Client (Coaching with Labs) Foundations Client (Coaching without Labs) Pay Per Session Client How did you hear about my services? DOB * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Height Weight Occupation What are your top health concerns? * What treatments have you tried? Has anything been successful? What are your health and wellness goals and why are they important to you? What is the most important thing you'd like to share from your health story? Do you currently have any medical diagnosis or conditions? If so, please list: Do you have a history of serious illnesses, hospitalizations, injuries, or surgeries? If so, please list: Is there anything from your childhood pertaining to your health you'd like to share? How many hours do you sleep per night (on average)? How would you describe your quality of sleep? How is your energy level most days? (1 = very low, 5 = very high) 1 2 3 4 5 Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain: Do you have any of the following metabolic health concerns? Please check all that apply. Blood Sugar Imbalances Elevated Cholesterol Elevated Triglycerides Elevated Blood Pressure Other If you selected other, please list here: Do you have any of the following digestive health concerns? Please select all that apply. Bloating Constipation Diarrhea Gas Nausea Stomach Pain GERD/Acid Reflux Other If you selected other, please list here: Do you have any of the following reproductive health concerns? Please check all that apply. Infertility Irregular Menstrual Cycle Low Libido Other If you selected other, please list here: Do you have any of the following hormonal health concerns? Please check all that apply. Thyroid Condition Sign or Symptoms of Hormonal Imbalance Toxin Exposure Other If you selected other, please list here: Do you have any of the following brain health concerns? Please check all that apply. Brain Fog Difficulty Concentrating Forgetfulness/Memory Loss Other If you selected other, please list here: Do you have any of the following immune health concerns? Please check all that apply. Autoimmune Conditions Frequent Illness or Infection Low Vitamin D Level Allergies and Sensitivities Other If you selected other, please list here: Are you currently on medications? If so, what medications and for how long have you been on them? Are you currently taking any supplements or herbs? If so, please list: Do you have any food allergies or intolerances? If so, please list: Do you follow a specific eating approach/practice for personal, health or religious reasons (e.g. vegan, ketogenic, kosher)? If so, please explain: Please describe your relationship with food. What does a typical day of eating look like for you? Please list a few foods/meals and drinks you usually consume for breakfast, lunch, dinner, and snacks. What if anything, would you like to change about your nutrition? Do you regularly use alcohol, weed, or tobacco? If so, how many times per week? How would you describe your overall mental and emotional health? What is your stress level most days? 1 = not stressed, 5 = extremely stressed 1 2 3 4 5 What are some practices you use to cope with stress and support your mental health? How many days per week do you exercise? 0 1-2 3-4 5-6 7 Are you prepared to prioritize your health? Yes! No Not sure yet As an inclusive practice, l acknowledge that labs can be costly and am committed to collaborating with you to develop a health plan that aligns with your financial means. Do you have a budget you'd like to share at this time? Is there anything else you'd like to share? Congratulations on taking steps toward better health, I am looking forward to being your partner in this journey! * I have read and understand everything on this page, I acknowledge that Dana Miller is a natural health practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Dana Miller, from any and all liability for any failure to identify any medicial condition or disease. It is understood and agreed that this is not the purpose of their natural health services. Thank you!
