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Nutrition HIPAA Intake Form
Please fill the form below
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Step 7
Full Name:
First Name
Last Name
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Preferred Name:
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Preferred Pronoun:
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Email Id:
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Mobile No:
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Address:
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City
State
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
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Austria
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Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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Zip Code
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Preferred Contact Method::
Phone call
Email
Text
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Gender::
Male
Female
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Patient Birth History ::
Vaginal delivery
C-section
Full term
Breast fed
Bottle fed
Unknown
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Blood type *:
Rh+
A+
Rh-
A-
AB+
AB-
B+
B-
O+
O-
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Genetic Heritage:
African American
Asian
Caucasian/European
Hispanic
Native Alaskan
Native Indian
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Family Medical History:
Mother
Father
Maternal Grandparent(s)
Paternal Grandparent(s)
Childrens
Inflammatory arthritis
Obesity
Osteoporosis
Pitting edema
Psoriasis
Varicose veins
Family Medical History:
Mother
Father
Maternal Grandparent(s)
Paternal Grandparent(s)
Childrens
Cancer
Heart Disease
Hypertension
Non-alcoholic fatty liver disease
Type I Diabetes
Type 2 Diabetes
Stroke
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Family Medical History:
Mother
Father
Maternal Grandparent(s)
Paternal Grandparent(s)
Childrens
ALS or other motor neuron diseases
Dementia/Alzheimer's disease
Graves' disease (hyperthyroidism)
Hashimoto's disease (hypothyroidism)
Multiple Sclerosis (MS)
other Autoimmune diseases (i.e. lupus)
Family Medical History:
Mother
Father
Maternal Grandparent(s)
Paternal Grandparent(s)
Childrens
Asthma
Celiac disease
Crohn's disease
Eczema/Psoriasis
Food Allergies/sensitivities
Environmental sensitivities
Inflammatory Bowel disease (IBD)
Irritable Bowel Syndrome (IBS)
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I am currently experiencing the following conditions:
Cardiac disease
Chest pain
Forgetfulness
Genitourinary
Lymphatic
Psychiatric
Weight gain, unexplained
Musculoskeletal
Restless/Restless Leg
Vertigo (dizziness)
Sleeplessness/Insomnia
Regurgitation, unexplained
Weight loss, unexplained
Respiratory
Neurological
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Personal Medical History:
Breast cancer:
Past
Present
Both
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Colon cancer:
Past
Present
Both
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Lung cancer:
Past
Present
Both
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Ovarian cancer:
Past
Present
Both
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Prostate cancer:
Past
Present
Both
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Arrhythmia:
Past
Present
Both
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Elevated cholesterol:
Past
Present
Both
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Hypertension:
Past
Present
Both
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Heart Attack:
Past
Present
Both
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Mitral valve prolapse:
Past
Present
Both
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Rheumatic fever:
Past
Present
Both
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Celiac disease:
Past
Present
Both
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Crohn's:
Past
Present
Both
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GERD (reflux):
Past
Present
Both
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IBS:
Past
Present
Both
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Peptic Ulcer disease:
Past
Present
Both
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Ulcerative Colitis:
Past
Present
Both
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Female Medical History:
Gestational Diabetes
Pre-term pregnancy
Toxemia
PMDD
Baby over 9 pounds
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Female Medical History:
Endometriosis
Fibroids
Infertility
PMDD
Painful menses
Heavy menses (periods)
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Female Medical History:
Concentration/Memory issues
Difficulty sleeping
Hot flashes
Mood Swings
Weight gain
Heavy menses (periods)
Vaginal dryness
Palpitations
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Are you currently taking any medication:
Yes
No
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Do you have any medication allergies:
Yes
No
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Medication History:
Currently
Past Use
Rarely Used
Never
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Medication and Vitamin List:
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Do you use or do you have history of using tobacco:
Yes
No
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Do you use or do you have history of using illegal drugs:
Yes
No
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How often do you consume alcohol:
Daily
Weekly
Monthly
Occasionally
Never
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What did you eat today:
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On average, I sleep:
8 hours/night, uninterrupted
5-7 hours/night, uninterrupted
3-4 hours/night, uninterrupted
1-2 hours/night, uninterrupted
Insomnia
8 hours/night, interrupted
5-7 hours/night, interrupted
3-4 hours/night, interrupted
1-2 hours/night, interrupted
Others
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On average, I exercise:
5-7 days a week for at least 30 minutes
2-4 days a week for at least 30 minutes
1 day a week for at least 30 minutes
Occasionally
Rarely
Never
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Please specify:
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Occupation/Job Title:
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Personal Wellness Scale:
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Please list any significant physical trauma you've experienced:
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Please list any emotional trauma you've experienced in your life:
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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:
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Please list your wellness Goals :
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What is your why:
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Please upload any other documents you see necessary to achieve your health and wellness goals:
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I agree to terms & conditions
I agree to terms & conditions
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E-Signature:
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