First Name
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Last Name
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Address
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City
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State
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Zip
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Email Address
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Phone Number
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Time Zone
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Skype Name
Birth Date
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Please scroll to select month and year.
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Age
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Place of Birth
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Height (feet, inches)
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Weight (lbs.)
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Gender
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Occupation
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Referred By (If working with an IHP coach, please list name)
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Todays Date
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DD
YYYY
Describe Problem(s)
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What treatments have you tried?
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Has anything been successful?
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Have you lived or traveled outside of the United States? If so, when and where?
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Have you or your family recently experienced any major life changes? If yes, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you lost from work or school in the past year?
Previous jobs:
Did you feel safe growing up?
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Have you been involved in abusive relationships in your life?
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Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
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Do you feel safe, respected and valued in your current relationship?
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Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
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Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues?
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Please list any allergies or intolerances (food or environmental):
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List past Medical and Surgical History:
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List previous hospitalizations:
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What medications are you taking now? (including birth control/hormones)
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List all vitamins, minerals, and other nutritional supplements that you are taking now.
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Were you a full term baby? A preemie? Breast-fed or Bottle-fed?
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As a child did you eat a lot of sugar and/or candy?
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What is your typical daily diet:
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(List typical meals and snacks)
How much of the following do you consume each week?
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(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)
Are you on a special diet?
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Is there anything special about your diet that 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 or supplement(s)?
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Does skipping a meal greatly affect your symptoms?
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Have you ever had a food that you craved or really "binged" on over a period of time?
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Do you have an aversion to certain foods? If yes, what foods?
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Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?
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Do you have intestinal gas? If so, when.
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How many times per week do you drink alcohol?
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Have you ever used recreational drugs?
Have you ever used tobacco? (If so, for how long?)
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Are you exposed to secondhand smoke regularly?
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Do you have mercury amalgam fillings in your teeth? If so, how many?
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Do you have any artificial joints or implants? If so, which ones.
Do you feel worse at certain times of the year?
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Have you, to your knowledge, been exposed to toxic metals in your job or at home?
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Do odors affect you? If so, which ones?
How would you rate your current level of stress?
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Women: If you have a cycle, 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:
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Do you exercise regularly? If so, how many times a week?
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What type of exercise is it?
Do you struggle with insomnia or interrupted sleep?
Do your parents or siblings have (or had) any health issues? If so, please explain:
Please add any other information you feel is important:
Why do you believe you would be a good candidate to work with me?
Congratulations, you are on the path to taking your first step towards health and wellness!
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