Health Intake Questionnaire Designed Family Wellness "*" indicates required fields Step 1 of 6 16% Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone*Skype NameBirth Date* MM slash DD slash YYYY Place of Birth*Height*Weight*Gender*Occupation*Referred ByDescribe Problem(s)* Does skipping a meal greatly affect your symptoms?Do you have an aversion to certain foods? If yes, what foods?*How many bowel movements (BM) do you have per day?*Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?*Do you have intestinal gas? If so, when.*How many times per week do you drink alcohol?*Have you ever used recreational drugs?*Have you ever used tobacco? (If so, for how long?)*Are you exposed to secondhand smoke regularly?*Do you have mercury amalgam fillings in your teeth? If so, how many?* Do you have any artificial joints or implants? If so, 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?*Have you ever had psychotherapy or counseling?*Are you currently, or have you ever been, married?*Do you exercise regularly? If so, how many times a week?*What type of exercise is it?*Do your parents or siblings have (or had) any health issues? If so, please explain:* 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?*What is your typical daily diet:*How much of the following do you consume each week?Tea:Coffee:Soda:Other Caffeine:Cheese:Bread:Dairy:Sugar:Candy/Chocolate:Dessert:Are you on a special diet?*Is there anything special about your diet that we should know?*Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symtpoms associated with any particular food or supplement(s)?*Do you feel much worse when you eat certain foods?*Do you feel much better when you eat certain foods?* What treatments have you tried?*Has anything been successful?*With whom do you live?*Do you have any pets or farm animals? If yes, where do they live?*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 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?*Have you been involved in abusive relationships in your life?* Congratulations, you are on the path to taking your first step towards health and wellness! I have read and understand everything on this page. I acknowledge Kelly Meehan is a health practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Kelly Meehan, her lab partners, independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.Date* MM slash DD slash YYYY Signature*Consent I agree to the privacy policy.
