Client Intake Form

Please provide details about your health situation:

Name*

City, state, country

Age*

Gender*

Male

Female

Weight and recent gains or losses?*

Height*

% Body fat if known

Thyroid labwork (free T4, Free T3, Reverse T3, TSH, antibodies)

Daytime temperature (and, does it drop after meals?)

Sex hormone labwork (include day of menstrual cycle if ovulating)

Menstrual cycle (women)

Regular (28 days)

Irregular

No periods/menopausal

Prepubescent

What are your EMF sources & what have you done to mitigate them?*

Describe your sleep - sleep & wake times, duration, interruptions & causes*

How many calories are you eating per day?*

How frequently are you eating?*

What types of carbs are you eating?*

What % fat, carbs & protein are you eating? Is every meal this balance?*

What are your protein sources?

What are your fat sources?*

What diets have you done in the past (carnivore, keto, low-calorie, fasting, etc)*

Any digestion issues (gas, bloating, pain, etc)

Any notable stressors right now? (Financial, relationship, environment, etc)

Allergies

Skin issues?

Hair issues? (Including greying)

Vaginal issues? (Women)

Libido issues?

Brain/cognition/memory/mood issues?

Head trauma/whiplash history

History of emotional trauma(s)

Yes

Exercise (types, duration, frequency)*

Pain?

Rx/drugs used

Supplements currently taking

Health diagnoses

History of cancer? (When? Location/type and current status)

Symptoms

Main issues you want help with right now*