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Women's Intake Form (NTA)
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Name
Mrs
Ms
Email
Age
Place of Birth
Gender
*
Female
Male
Height
Current Weight
Would you like your weight to be different? If so, what?
Blood Type
A
B
AB
O
Occupation
How many hours do you work per week?
Relationship Status
Single
Married
Separated
Divorced
It's complicated
Pets
What hobbies or activities do you enjoy?
What are your top five health concerns?
What would you like to accomplish or gain from this consultation?
Do you sleep well?
Do you wake up during the night? If so, what time(s)?
What time do you go to bed?
What time do you generally wake up?
How do you feel when you wake up?
Do you drink caffeinated beverages?
Every day
A few times a week
Once a week
Rarely
Others
What types of caffeinated beverages do you consume?
Coffee
Decaf
Black Tea
Green Tea
Chocolate
Sodas
Red Bull
Others
How many total daily ounces of caffeinated beverages do you consume?
Do you smoke?
Yes, daily
Yes, occasionally
No, I quit
Never
If yes, how much and how often?
If you quit, how and how long ago?
Have you been or are you exposed to secondhand smoke?
If so, how and how long?
Do you drink soda?
Yes, regular soda
Yes, diet soda
No
Others
If drinking soda, how much and how often?
Do you drink alcohol?
Yes, daily
Yes, a few times a week
Yes, rarely
Never
Others
if drinking alcohol, what do you drink and how much?
Have you been exposed to toxic substances at home or at work?
Do you have any allergies?
How much water do you drink per day?
What role does exercise play in your life?
Prescription & Non-Prescription Drugs & Supplements
Do you have any known allergies to medications or herbs?
Yes
No
Others
If you have allergies, please list all:
Are you currently under a practitioner's care for specific health issues?
Yes
No
Others
If so, what treatments are you undergoing?
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and date:
What were your eating habits like as a child? Please list types of food you ate regularly.
What percentage of your food is home-cooked?
How often do you eat out?
What are the three worst foods you eat each week?
What are the three healthiest foods you eat each week?
Do you crave sugar?
Yes
No
Others
Do you crave salt?
Yes
No
Others
Do you feel tired, bloated, and/or gassy after meals?
Yes
No
Others
Do you experience constipation or diarrhea often?
Yes
No
Others
If so, when and how often?
Do you feel excessively hungry?
Yes
No
Others
Do you have poor appetite?
Yes
No
Others
Please indicate family history of:
Diabetes
Kidney disease
Asthma
Heart disease
Arthritis
Gallbladder disease
Stomach/Intestinal Disorder
Cancer (list type of cancer below)
Others
Comments on family health history:
Mother's Age:
Father's Age:
Maternal Grandmother's Age:
Paternal Grandmother's Age:
Maternal Grandfather's Age:
Paternal Grandfather's Age:
Mother died from:
Father died from:
Maternal Grandmother died from:
Paternal Grandmother died from:
Maternal Grandfather died from:
Paternal Grandfather died from:
Age of your first period:
Number of pregnancies:
Are you peri-menopausal?
Yes
No
Others
Are you menopausal?
Yes
No
Others
Are/were your periods regular?
How many days is/was your flow?
When did peri-menopausal symptoms first occur?
When was your last period?
List your symptoms or peri/menopause:
How frequent are/were your periods?
Do you experience PMS?
Yes
No
Others
If so, is your PMS mild or severe?
Mild
Severe
How many children have you delivered and how were they born (vaginally or cesarean)?
Were there complications associated with those births?
Please explain:
Did you receive antibiotics during labor?
Yes
No
Others
Have you had any miscarriage(s) or abortion(s)?
None
Miscarriage(s)
Abortion(s)
Others
Please add anything else you wish to share:
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