Health and Lifestyle Intake Form/Retreat
Date
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Prefferred Name
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Genetic Background
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African American
Native American
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Caucasian
Northern European
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Address
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Street Address
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State / Province
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Afghanistan
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The Bahamas
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Barbados
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Belgium
Belize
Benin
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
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Burkina Faso
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Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
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China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Cote d'Ivoire
Croatia
Cuba
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Cyprus
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French Polynesia
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The Gambia
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Iran
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Ireland
Israel
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Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
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Laos
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Lebanon
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Liberia
Libya
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Lithuania
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Madagascar
Malawi
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Maldives
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Marshall Islands
Martinique
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Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
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Palestine
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Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
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Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Solomon Islands
Somalia
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South Africa
South Ossetia
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eSwatini
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Preferred Primary Phone
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Area Code
Phone Number
Secondary Phone
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Area Code
Phone Number
Fax
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Area Code
Phone Number
E-mail
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Best way to contact?
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Primary Physician
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Name
Email
Phone
City
Referred By
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Complaints / Concerns
What do you hope to achieve in your visit(s)?
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Nutritional Habits
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Fast eater
Struggle with eating
Love to cook
Negative relationship with food
Love to eat
"Eat because I have to" issues
Erratic eating patterns
Emotional eater
Eat too much/overeat
Eat fast food frequently
Late night eating
Live or often eats alone
Don't drink enough water
Confused about food/nutrition
Time constraints
Family members have different tastes
Dislike "healthy food"
Rely on convenience items
Poor snack choices
Do not plan meals
Travel frequently
Vegan
Vegetarian
Macrobiotic
High Protein
Organic
Local
Raw Foods
Standard American Diet (USDA)
Gluten/Casein Free
Name your three main health/nutrition concerns you would like to remove from your life if you could.
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What sensitivities/allergies do you have, if any?
Do you keep them under control? How?
Can you recall when was the last time you felt well?
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Did something trigger your change in health?
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What makes you feel better?
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What makes you feel worse?
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Additional Comments:
Check all the factors that apply to your current lifestyle and eating habits:
Are you taking medications? Specify the condition each one is for?
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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
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Please Select
Yes
No
Please indicate the type of exercise you are currently engaging in.
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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:
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Daily Stressors
Rate on a scale of 1 (low) to 10 (high)
Work
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Low
High
1 is Low, 10 is High
Family
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Low
High
1 is Low, 10 is High
Relationships
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Low
High
1 is Low, 10 is High
Finances
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1
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Low
High
1 is Low, 10 is High
Health
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1
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Low
High
1 is Low, 10 is High
Education
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Low
High
1 is Low, 10 is High
Physical Activity
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1
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Low
High
1 is Low, 10 is High
Career Choice
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Low
High
1 is Low, 10 is High
Politics
Lifestyle Information
Is there any unusual excess stress in your life?
*
Please Select
Yes
No
Please explain:
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Do you easily handle stress?
*
Please Select
Yes
No
How do you handle stress? Please explain:
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What nourishes you Spiritually/Emotionally?
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Do you wake up during the night?
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Please Select
Yes
No
If yes, how many times?
How would you rate the overall quality of your sleep? (0-low, 5-high)
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How many hours of sleep do you get a night?
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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
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 meditation
Engage in regular exercise/physical activity
What do you think would make the most difference in your overall health?
*
Signature
*
Signature & Date
INFORMED CONSENT
I am solely responsible for the decision to see Beth Stoller, LMT for CranioSacral Therapy, Massage and Aromatherapy. I recognize that some recommendations may not prove to be successful. I understand some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concerns to Beth Stoller, LMT. I also understand that any significant symptoms should be reported to my doctor. It is also recommended that although the aromatherapy is Certified Pure Therapeutic Grade Essential Oil, it is recommended to consult with your doctor in case of any contraindications with medications.
Signature
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Signature & Date
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E-mail
bethe777@gmail.com
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