Skip to content

Client Intake Form

How much time have you had to take off from work or your daily activities in the last year? (required)

How have you dealt with these concerns in the past? (required)
DoctorSelf-careAlternative medicineNothingSomething else

Which of these foods do you consume regularly? (required)
SodaDiet sodaRefined sugarAlcoholFast foodGlutenDairyCoffeeNone of the above

Are you currently on a special diet? (required)
PaleoGAPSDairy-freeVegetarianVeganBlood typeRawSugar-freeGluten-freeOther

What percentage of meals are home-cooked? (required)

Bowel Movement Frequency (required)

Bowel Movement Consistency (required)
Soft & well formedOften floatsDifficult to passDiarrheaThinLong or narrowSmall & hardLoose but not wateryAlternating between hard and loose

Bowel Movement Color (required)
BrownVery dark or blackGreenishBlood is visibleVariableyellowLight brownChalky colouredGreasyShiny

Please check any of the following conditions that apply to your history: (required)
CancerHeart diseaseHepatitisVenereal diseaseDiabetesHigh blood pressureHigh cholesterolKidney diseaseThyroid diseaseDepressionAsthmaAllergiesAnemiaChronic yeast infectionsConcussions or head injuries (major or minor)Eating disorderOther

Do you ever experience the following: (required))
Short term memory impairmentShortened focus of attention and ability to concentrateCoordination and balance problemsProblems with lack of inhibitionPoor organization abilitiesProblems with time management (late or forgetting appointments)Mood instabilityDifficulty understanding speech and word findingBrain fog/brain fatigueLower effectiveness at work/home/schoolJudgment problems like leaving the stove on