FEWL Intake Form

Basic Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone (Cell)*
Phone (Home)
Do you like to communicate via text message?
- Yes
- No
Skype Number or ID
Email*
Referred By
Age
Birth Date
Date Format: MM slash DD slash YYYY
Height
Blood Type (if known)
Birth Weight (if known)
Current Weight
Ideal Weight
Weight One Year Ago
Family / Living Situation
Children
Occupation
Exercise / Recreation

History
1. Have you lived or traveled outside of the United States? If so, when and where?
2. Have you or your family recently experienced any major life changes? If so, please comment:
3. Have you experienced any major losses in life? If so, please comment:
4. How much time have you had to take off from work or school in the last year?
- 0 to 2 days
- 3 to 14 days
- more than 15 days
Health Concerns
7. Have you experienced any success with these approaches?
- Yes
- No
8. What other health practitioners are you currently seeing? List name, specialty and phone # below.
9. Please list the date and description of any surgical procedures you have had.
10. How often did you take antibiotics in infancy/childhood?
11. How often have you taken antibiotics as a teen?
12. How often have you taken antibiotics as an adult?
13. List any medicine you are currently taking:
14. List all vitamins, minerals, herbs and nutritional supplements you are now taking:
15. Have any other family members had similar problems (describe)?

Lifestyle History
36. Have you had periods of eating junk food, binge eating or dieting? If yes, please describe:
37. List any known diet that you have been on for a significant amount of time.
38. Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
39. How well do you handle stress? What are your stress management techniques (if any)?
Sleep History
40. Are you satisfied with your sleep? If NO, describe:
41. Describe the quality of your sleep?
42. What time do you go to sleep?
43. Do you fall asleep easily?
- Yes
- No
44. Do you wake up during the night? If so, how often?
45. Do you sleep between 6 and 8 hours per night?
- Yes
- No

Mental Health Status
55. How are your moods in general?
56. Do you experience more anxiety, depression or anger than you would like? If yes, please describe:
57. On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
58. At what point in your life did you feel best? Why?
Other
59. Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
60. Who in your family or on your health care team will be most supportive of you making dietary changes?
61. Please describe any other information you think would be useful in helping to address your health concern(s):
62. What are your main health goals and aspirations?
63. Please explain WHY you might want to achieve that for yourself:

Basic Information