Private Wellness Client Application – Vital Balance Wellness Coaching

The health intake from below is a standard wellness client intake form used in Functional Medicine to get a more complete health history.

Accurately assessing all the factors and comprehensively addressing them is the best way to deal with health challenges. Your careful consideration of each of the following questions will allow for more effective use of your scheduled consultation time. These questions will help identify underlying root causes of your symptoms and will also assist in formulating a Personal Health Plan.

* = Required

Name *

First

Last

Street Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

Time Zone *

Birth Date *

Age *

Place of Birth *

Height (feet & inches) *

Weight (lbs) *

Gender *

Male
Female

Occupation *

Referred by:

Today's Date *

Describe Problem(s): *

What treatments have you tried? *

Has anything been successful? *

With whom do you live? *

Please include relationship (child, parent, friend, sister/brother, etc.) and age. Example: "Wendy, age 7, sister"

Do you have any pets or farm animals? If yes, where do they live (outdoors/indoors)? *

Have you lived or traveled outside of the United States? If so, when and where? *

Have you or your family recently experienced any major life changes? If yes, please comment:

Have you experienced any major losses in life? If yes, please comment:

How much time (if any) have you lost from work or school in the past year due to your health issue(s)?

What previous jobs have you held? What job do you currently hold?

Did you feel safe growing up? *

Have you been involved in abusive relationships in your life? *

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *

Do you feel safe, respected, and valued in your current relationship? *

Yes
No
Not applicable

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *

Would you feel safer discussing any of these issues privately, or would you prefer not to speak about these issues? *

I would be open to discussing them privately
I would prefer not to speak about them

Please list any known allergies or intolerances (food or environmental): *

List past Medical and Surgical History: *

List previous hospitalizations: *

How often have you taken antibiotics? *

(as a child and an adult)

How often have you have taken oral steroids? *

(e.g. Cortisone, Prednisone, etc.)

What medications are you currently taking (including birth control/hormones)? *

What vitamins, minerals, or other nutritional supplements are you currently taking? *

Were you a full term baby? A preemie? Breast-fed or bottle-fed? *

As a child, did you eat a lot of sugar and/or candy? *

Describe your typical daily diet. *

(list typical meals and snacks)

How much of the following do you consume each week? *

Tea, coffee, soda, other caffeine, dairy (milk/cheese/yogurt/butter, etc.), bread, sugar, candy, chocolate, dessert

Are you on a special diet? *

Is there anything special about your diet I should know?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food(s) or supplement(s)? *

Do you feel much worse when you eat certain foods? *

(e.g. fat, protein, carbs, specific foods)

Do you feel much better when you eat certain foods? *

(e.g. fat, protein, carbs, specific foods)

Does skipping a meal greatly affect your symptoms? *

Have you ever had a food that you craved or really "binged" on over a period of time? *

Do you have an aversion to certain foods? If yes, what foods? *

How many bowel movements do you have per day? *

(give a range, e.g. 0-1, 1-2, 2-3, 3 or more)

Do you have any constipation (straining or less than 1 bowel movement per day) or diarrhea (loose stool)? *

Do you have intestinal gas? If yes, when? *

How many times per week (if any) do you drink alcohol? *

Have you ever used recreational drugs? (Optional)

Have you ever used tobacco? If yes, when and for how long? *

Are you exposed to secondhand smoke regularly? *

Do you have mercury amalgam "silver" fillings in your teeth? If yes, how many? *

Do you have any artificial joints or implants? If yes, which ones? *

Do you feel worse at certain times of the year? *

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

Do odors affect you? If so, which ones?

How would you rate your current level of stress? *

Women: Do you have a cycle? If yes, how long is it, and is it regular?

Women: Do you have any problematic symptoms related to your cycle?

Women: Any other comments related to your cycle?

(flow, clots, mood changes, etc.)

Have you ever had psychotherapy or counseling?

List your hobbies and leisure activities: *

Do you exercise regularly? If yes, how many times a week, and what type(s) of exercise (e.g. walking, bodyweight, free weight, steady-state cardio, intervals, etc.)? *

Do you struggle with insomnia or interrupted sleep? *

Around when do you go to bed? *

Around when do you wake up? *

Do your parents or siblings have (or have they, in the past, had) any health issues? If yes, please explain: *

Please add any other information you feel is important:

Why do you believe that you would be a good candidate to work with Pierce Whitley? *

Are you prepared to invest time, money, and effort into your health? *

I wish to apply to Pierce Whitley's Private Health & Wellness Practice, I agree to pay the fees associated with this program.

Congratulations, you are on the path to taking your first step toward health and wellness! *

I have read and understand everything on this page. I acknowledge that Pierce Whitley is a natural health practitioner and does not diagnose, cure, treat, or prevent any illness, disease, or medical condition. Furthermore, I release Pierce Whitley and his associates, affiliates, and partners from any and all liability for any failure to identify any medical illness, disease, or condition. I understand and agree that this is not the purpose of their natural health services.

Phone

Adult Health Intake Form