HIPAA Nutrition Intake Form

Full Name*
First NameLast Name
Preferred Name
Preferred Pronoun*
(i.e. she, he, him, her, us, them)
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number*
Area CodePhone Number
Email

Confirmation Emailexample@example.com
Preferred Contact Method
Phone callEmailTextOther
Birth Date*
MonthDayYear
Patient Birth History*
Vaginal deliveryC-sectionFull termPrematureBreast fedBottle fedUnknownOther
What is your Gender?*
MaleFemaleOther
Blood type*
ABABORh+Rh-Unknown
Genetic Heritage
African AmericanAsianCaucasian/EuropeanHispanicNative AlaskanNative IndianNative Hawaiian and other Pacific IslanderOther

Family Medical History

	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
Inflammatory arthritis	1	2	3	4	5	6
Obesity	7	8	9	10	11	12
Osteoporosis	13	14	15	16	17	18
Pitting edema	19	20	21	22	23	24
Psoriasis	25	26	27	28	29	30
Varicose veins	31	32	33	34	35	36

Family Medical History

	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
Cancer	37	38	39	40	41	42
Heart Disease	43	44	45	46	47	48
Hypertension	49	50	51	52	53	54
Non-alcoholic fatty liver disease	55	56	57	58	59	60
Type I Diabetes	61	62	63	64	65	66
Type 2 Diabetes	67	68	69	70	71	72
Stroke	73	74	75	76	77	78

Family Medical History

	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
ALS or other motor neuron diseases	79	80	81	82	83	84
Dementia/Alzheimer's disease	85	86	87	88	89	90
Graves' disease (hyperthyroidism)	91	92	93	94	95	96
Hashimoto's disease (hypothyroidism)	97	98	99	100	101	102
Multiple Sclerosis (MS)	103	104	105	106	107	108
other Autoimmune diseases (i.e. lupus)	109	110	111	112	113	114

Family Medical History

	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
Asthma	115	116	117	118	119	120
Celiac disease	121	122	123	124	125	126
Crohn's disease	127	128	129	130	131	132
Eczema/Psoriasis	133	134	135	136	137	138
Food Allergies/sensitivities	139	140	141	142	143	144
Environmental sensitivities	145	146	147	148	149	150
Inflammatory Bowel disease (IBD)	151	152	153	154	155	156
Irritable Bowel Syndrome (IBS)	157	158	159	160	161	162

Family Medical History

	Mother	Father	Sibling(s)	Maternal Grandparent(s)	Paternal Grandparent(s)	Children
ADD/ADHD	163	164	165	166	167	168
Autism	169	170	171	172	173	174
Bipolar disorder	175	176	177	178	179	180
Depression	181	182	183	184	185	186
Psychiatric disorder(s)	187	188	189	190	191	192
Schizophrenia	193	194	195	196	197	198

I am currently experiencing the following conditions...*
Cardiac diseaseCardiovascularChest painDiarrheaForgetfulnessGastrointestinal distressGenitourinaryHematological (blood)LymphaticNeurologicalPsychiatricRespiratoryWeight gain, unexplainedWeight loss, unexplainedMusculoskeletalRegurgitation, unexplainedRestless/Restless LegSleeplessness/InsomniaVertigo (dizziness)Other
Hi There!
Great work so far! A quick heads-up about the next portion. The "Personal Medical History" section requires selecting either acute, chronic, past, present, or both, in reference to medical conditions you currently may be experiencing or have in the past. Please be honest and only select the conditions that apply to you, specifically.
Thank you for your time and effort and Remember to be Your Best Friend and Advocate Always!
Happy Healing
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
Personal Medical History
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Personal Medical History
Personal Medical History
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Personal Medical History
Female Medical History
Female Medical History
Female Medical History
EndometriosisFibrocystic breastsFibroidsHeavy menses (periods)InfertilityPainful mensesPMDDOther
Female Medical History
Gestational DiabetesFull-term pregnancyPre-term pregnancyPostpartum depressionToxemiaBaby over 9 poundsPMDDOther
Female Medical History
Concentration/Memory issuesDecreased libidoDifficulty sleepingHeadachesHot flashesLoss of bladder/urine controlMood SwingsPalpitationsWeight gainVaginal drynessOther
Male Medical History
Change in libidoDifficulty obtaining an erectionDifficulty maintaining an erectionFrequent urination at nightImpotenceLoss of urine controlProstate enlargementProstate infectionUrgency/Hesitancy/Stream chg.Other
Personal Dental History
Bleeding gumsFloss regularlyGingivitisGold fillingsImplant(s)Root canal(s)Silver Mercury fillingTooth painOther
Are you currently taking any medication?*
YesNo
Medication History*
Medication History*
Medication History*
Medication History*
Medication History*
Medication History*
Medication and Vitamin List
Do you have any medication allergies?*
YesNoNot Sure
Do you use or do you have history of using tobacco?*
Do you use or do you have history of using illegal drugs?*
How often do you consume alcohol?*
DailyWeeklyMonthlyOccasionallyNever
What did you eat today?
On average, I sleep...*
8 hours/night, uninterrupted8 hours/night, interrupted5-7 hours/night, uninterrupted5-7 hours/night, interrupted3-4 hours/night, uninterrupted3-4 hours/night, interrupted1-2 hours/night, uninterrupted1-2 hours/night, interruptedInsomniaOther
On average, I exercise...*
5-7 days a week for at least 30 minutes2-4 days a week for at least 30 minutes1 day a week for at least 30 minutesOccasionallyRarelyNever
Occupation/Job Title
Please include any specific physical demands needed to perform job
Personal Wellness Scale *
This matrix type is not available for legacy form layout.
Please list any significant physical trauma you've experienced:
Please list any emotional trauma you've experienced in your life:
When was the last time you felt well? *
Did something prompt your change towards health and wellness, in the past and/or recently? Please list and give a brief description for each item listed.
Please list Your Wellness Goals *
What is Your Why?
Please upload any other documents you see necessary to achieve your health and wellness goals.
Browse Files
(i.e. lab tests, medical files, medication list...)Cancelof
E-Signature
Clear
Please verify that you are human*
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