CLIENT INTAKE FORMS

DIRECTIONS FOR COMPLETING INITIAL INTAKE FORMS

Thanks for your interest in working with me on your current health issues.  Nutrition has been helpful and supportive for many health problems, not only in the literature, but in my private practice.  To help use our appointment time most productively and to let me know more about your health, metabolism, and symptomology, please complete the following.  While this takes a bit of your time and requires a certain commitment, it is a big step toward understanding the underlying causes for sub-optimal health.  I want to be as thorough as possible in doing the intake.   Four forms, one as .pdf, and three as .doc, have been attached.

3-Day Food/Fluid Record -  Please print enough copies for 3 full days and be as specific as possible about all intake, including precise amounts, brands of prepared/packaged foods, fluids, medications, and supplements. 

Health Evaluation Profile - Use extra paper as needed to explain your current concerns, previous care, and goals of our work together. 

Health Appraisal Questionnaire - While time-consuming, this gives me a wealth of information to help “triangulate” on the health issues.  Note: fill out for how you have felt the past four months.

Consent Form - informs you of my scope of practice, training, and what you need to know when working with me.  

Obtain and send copies of any laboratory work that you have had done within the last 6-12 months only.   If you can, send those with your advance paperwork so I can review them before we meet. You can regular mail, or scan and email your paperwork to me.  I must have your completed paperwork in hand at least 3 working days prior to our scheduled appointment.  If you need to reschedule, note that I need 24 hours’ notice.

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I look forward to our work together!

Warm regards,

Nori