Client Intake & Consent

Full Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

Gender

How will you be checking in?

How did you hear about this program?

Are you under the care of a qualified healthcare professional? Please list whom.

As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise, and is monitoring medications and any health concerns that you list here (besides stress and weight issues). If you are on medications (particularly for high blood pressure or hypothyroidism), you will need these to be monitored during and after the program as your need for them may change.

What medications, supplements and over the counter items do you take regularly or are currently prescribed (please indicate dosage for each):

Any past surgeries and hospitalizations?

Do you exercise regularly? Please detail.

What kind of other movement or activities do you enjoy?

You have problems falling or staying asleep?

How many hours do you sleep?

Do you wake up refreshed?

How is your energy?

Does your energy level affect your daily activities?

How would describe your mood, generally:

Does your mood affect your life or daily activities?

How would you describe your stress level?

What are your sources of stress?

How do you manage stress?

Do you have people close to you who support you?

Do you regularly drink alcoholic beverages?

If yes, how many per week?

Do you smoke tobacco?

Do you use recreational drugs?

How is your appetite?

How many meals per day do you eat?

What is a typical day, in terms of food intake? Please list all meals and snacks.

How much fluids do you normally drink? Please approximate in ounces.

Please list all types of beverages you regularly drink.

Please list any food allergies, intolerances or foods you avoid and the reason.

What past struggles and difficulties have you experienced in terms of food and dieting?

What diet and exercise programs, protocols, plans or approaches have you tried in the past?

What types of diet and exercise approaches have worked for you in the past?

And what hasn't worked for you at all?

Health History

Rows	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue, lack of energy, lack or endurance
Unexplained weight loss or gain. Difficulty maintaining ideal weight.
Change in appetite
Depressive symptoms/Feeling down, uninterested, or moody
Anxiety
Mood swings
Nervousness/ Frequently feeling fearful or timid
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Poor concentration/memory
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar/junk food cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain, feeling sore or stiffness
Muscle weakness, cramps, spasms, or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Blelching/gas
Constipation or only 1 bowel movement per day
Diarrhea
Daily bowel movements
Illness more than twice a year.
Monthly female concerns
Food allergies
Heavy coating on tongue
Cravings for sweets or junk food
Body odor and/bad breath
Recent or frequent use of antibiotics
Puffiness under eyes
Daily consumption of dairy products
Menopausal concerns
Dry, damaged, or dull hair
Restless sleep or waking up frequently
Feeling irritable or easily angered
Frequent urination or urinary concerns
Weak knees, ankles, or back
Daily consumption of fried foods
Recurrent yeast or fungal infections
Do not exercise regularly
Difficulty digesting certain foods
Regular consumption of alcohol
Smoking
Stressful lifestyle
Less than 3 servings of fruits & veggies daily
Gum problems or redness on nose
Skin/complexion problems
Diet high in meat and grains
Low sex drive
Caffeinated beverages daily
Weak bones, teeth, or cartilage
Respiratory concerns

What are your top preferences for checking in?

Rows	Top choice	Works ok	Doesn't work for me
Monday morning (9am-noon)
Monday afternoon (noon-5pm)
Tuesday morning (9am-noon)
Tuesday afternoon (noon-5pm)
Wednesday morning (9am-noon)
Wednesday afternoon (noon-5pm)
Thursday morning (9am-noon)
Thursday afternoon (noon-5pm)
Friday morning (9am-noon)
Friday afternoon (noon-5pm)

The above are my standard office hours of operation. If none of the above work, please list days and times that would and I will try to work something out with you.

I have read and answered the following documents fully. By signing this I agree that: 1)All information provided is current and truthful. 2) I am aware that all information provided will be kept under the strictest confidence. 3) I understand that Tina L. Korotky is not here to diagnose or take the place of any medical professional, and she will not be held responsible for any decisions I make about my health. 4) I will discuss my natural healthcare plan with my current physician. (please sign electronically with your cursor below).

Just one last box to write here anything important that you'd like me to know before we begin.

Client Intake & Consent

Natural Health Solutions & Reiki...

General Information

Medical History

Personal History

Diet and lifestyle

Let's get a current picture of your health