Good Land Wellness Client Intake Form

Client Intake Form
Date*

MonthDayYear
Full Name*

First NameMiddle NameLast Name
Prefferred Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
E-mail*
Best way to contact?*
Primary Physician*
Name
Email
Phone
City
Other Pertinent Provider
Name
Email
Phone
City
Referred By*
Complaints / Concerns
What do you hope to achieve in your visit(s)?*
Reflection
Name your three main health/nutrition concerns you would like to remove from your life if you could.*
Can you recall when was the last time you felt well?*
Did something trigger your change in health?*
What makes you feel better?*
What makes you feel worse?*
Additional Comments:
Nutritional Status

Check all the factors that apply to your current lifestyle and eating habits:
Fast eaterStruggle with eatingLove to cookNegative relationship with foodLove to eat"Eat because I have to" issuesErratic eating patternsEmotional eaterEat too much/overeatEat fast food frequentlyLate night eatingLive or often eats aloneConfused about food/nutritionTime constraintsFamily members have different tastesDislike "healthy food"Rely on convenience itemsPoor snack choicesDo not plan mealsTravel frequentlyVeganVegetarianMacrobioticHigh ProteinOrganicLocalRaw FoodsStandard American Diet (USDA)Gluten-FreeGluten/Casein Free
Current weight
Height
Please note any additional comments about your nutrition/eating habits:*
Medical History
Please check under 'Never' if you have never had the problem, under 'In the past' if you have suffered from the problem in the past, or under 'At present' if you are presently suffering from the problem. If you are unsure - leave blank.

	Never	In the past	At present
Allerigies
Appendicitis
Asthma / Spastic Bronchitis
Cardiovascular problems
Cancer of any kind
Diabetes
Hypoglycemia
Drug use
Epilepsy / Seizures
Gall bladder problems
Gout
Heart Disease
Hernia of any kind
Hemorrhoids
High Blood Pressure
Kidney disease or kidney stones
Liver disease or liver infection (hepatitis, jaundice)
Rheumatic fever
Stroke
Organ transplant
STD
Thyroid disease
Tuberculosis
Duodenal ulcer
Migraines
Prostate problems
Bone density problems or osteoporosis
Mental illness, psychological/psychiatric treatment, attempted suicide
Parasites
Other:

Hospitalization: Please list your hospital stays, including your age and the reason for hospitalization.
Medicines: Please list all the medicines that you are taking now or have taken in the past month, and the dosage if you know it. Please also include non-prescription medicines, such as pain relievers, vitamins, minerals herbs...
Allergies and Sensitivities: Please list allergies to drugs, food allergies, and any other allergies.
Physical Activity
Do you engage in moderate cardiovascular physical activity for a minumum duration of 20 minutes at least 3 days a week? For example: brisk walking, jogging, cardio exercise classes*

Please indicate the type of exercise you are currently engaging in.*

	Type/Intensity (low/mod/high)	# Day Per Week	Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other

Note any problems that limit your physical activity:*
Daily Stressors

Rate on a scale of 1 (low) to 10 (high)

Work*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Family*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Relationships*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Finances*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Health*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Education*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Physical Activity*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Career Choice*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Other
Lifestyle Information
Is there any unusual excess stress in your life?*
Please explain:*
Do you easily handle stress?*
How do you handle stress? Please explain:*
What nourishes you?*
Do you wake up during the night?*
If yes, how many times?
How would you rate the overall quality of your sleep? (0-low, 5-high)*
How many hours of sleep do you get a night?*

In order to improve your health, how willing are you to:(Rate on scale of 5-very willing to 1-not willing)

	5	4	3	2	1
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits, exercise)
Practice a relaxation technique
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

Choose the options that apply.

Currently smokeSmoked in the past
Do you consume alcohol?

YesNo
How often?
Bowel Movements: No. times a day or week
What do you think would make the most difference in your overall health?*
Client Narrative

Please SHARE your health and medical story that would help us help you. SHARE your challenges and goals you would like to accomplish on this journey to wellness.
Good Land Wellness

NOTICE OF DISCLOSURE
The information provided by Good Land Wellness and its founder, Bracha Cale, is not intended to diagnose, treat, prevent or heal any ailment. The information provided is for educational purposes only, and should not replace any advice received from a physician or your health providers. You are solely responsible for your health and actions.

I hereby confirm that I am aware that the requested treatment is not a substitute for any conventional medical treatment, and that I do not intend to stop treatment without medical consultation. I hereby confirm that my answers to all the above questions are complete and correct, and that I have not concealed any information.
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Client Intake Form

Complaints / Concerns

Reflection

Nutritional Status

Medical History

Physical Activity

Daily Stressors

Lifestyle Information

Client Narrative

Good Land Wellness