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New Client Intake QuestionnaireWelcome! I look forward to working with you. To help me learn about you and your health, please fill out this form in as much detail as possible. My goal is to find the root cause of your health challenges

and in-depth information provides the pieces to that puzzle. Allow for 30 minutes.

Please fill out before your appointment and email to Support@BeBalancedHealing.com 1 – 2 days before our meeting so that I can review in advance to make

the most of our time together. Thank you!

Date ____________

Name ________________________________

Address _______________________________ City ____________ State _______ Zip _____________

Where did you grow up? _______________________________________

Email _______________________________________________________

Phone ________________________

How do you prefer to be contacted? __________________________

Sign up for e-newsletter for nutrition news, tips, events and recipes?

Age ________________________ How old do you feel? ________________________

Date of Birth ________________

Weight _____________________ Height ______________________

Marital Status

Do you have children? If so, how old are they?______________________________________________

Do you have pets? If so, what kind? _______________________________________________________

Occupation _________________________________ Do you enjoy your job?

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Employer ________________________________________________

Employment Status: Full Time Part Time Retired (when?) Student

What is the highest level of education you’ve achieved? ______________________________________

Who is your physician? _________________________________________________________________

How did you hear about my services? _____________________________________________________

Please list your main health concerns (in order of importance)

1.

2.

3.

4.

What would you like to change or improve?

Did something trigger the change in your health?

What are your expectations for seeking nutritional therapy?

HEALTH HISTORY

Please provide a brief history of your health. Include any previous surgeries and past or present

illnesses, hospitalizations, or discomforts.

Which health practitioners and doctors do you see? (list names, locations)

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Have you gained or lost a significant amount of weight in the past?

When? ________________________________ How much? ___________________________________

List the dietary and herbal supplements you take, with dosages:

Supplement & Brand Dose

List the over-the-counter medications and prescriptions you take:

Medication Dose Date started For What Condition

Do you have any allergies? If so, to what? __________________________________________________

How was your health as a child? List any conditions:

Were you breast fed? Formula-fed? Delivered vaginally or by caesarean?

What did your parents teach you about food?

DIGESTION AND ELMINATION HEALTH & HISTORY

How frequent are your bowel movements? ________________ # times per day or # times per week

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COLON HEALTH

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Diarrhea Loose, unformed stool

Constipation Hard, small stool

Strain to eliminate Urgency to eliminate

Alternating constipation and

diarrhea

Incomplete bowel emptying

Recurrent colds and infections Laxative use

Blood in stool Excessive gas

Mucus in stool Lower abdominal cramps alleviated

by passing gas or stool

Bloating Vaginal yeast infections

Toe or fingernail fungus History of antibiotics use

HYPOACIDITY OF STOMACH

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Excessive burping Feeling overly full after meals

Bloating Gas immediately after a meal

Offensive breath Undigested food in stools

Protein feels like it sits in stomach Poor appetite

Stomach upsets easily Known food allergies

Vomiting Nausea after taking supplements

Iron-deficiency anemia Foul smelling gas

HYPERACIDITY OF STOMACH

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Stomach pain, burning 1-4 hours

after a meal

Family history of ulcer or gastritis

Antacid or proton pump inhibitor

use

Stomach pain before meals

Heartburn Temp relief from antacids, food, milk

or carbonated beverages

Digestive problems subside with

relaxation but increase with stress

Heartburn from spicy foods,

chocolate, citrus, peppers, alcohol,

caffeine

Burping Current ulcer

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INTESTINAL PERMEABILITY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Abdominal pain or bloating Joint pain or swelling, arthritis

Frequent fatigue Food allergy, sensitivity or

intolerance

Sinus or nasal congestion Eczema or psoriasis

Hives Skin rashes

Asthma Seasonal allergies or hay fever

Poor memory Mood swings

Use of aspirin or NSAIDs (ibuprofen,

Aleve, Motrin, Advil, etc.)

History of antibiotic use

Alcohol makes you feel sick Ulcerative colitis, Crohn’s or celiac

Headaches Migraines

LIVER AND GALLBLADDER HEALTH

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Intolerance to greasy foods Headaches after eating

Light-colored stool Stools that float

Less than one bowel movement a

day

Sour taste in mouth

Fatigue after eating Gray-colored skin

Yellow in the whites of eyes Pain when passing stool

Dry skin or hair Acne

Triglyceride level above 115 Total cholesterol above 200

Bumps on the back of arms PMS symptoms

Keratosis Nausea after eating fatty or greasy

foods

HYPOFUNCTION OF SMALL INTESTINES AND/OR PANCREAS

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Abdominal cramps Fatigue after eating

Fiber causes constipation Three or more large bowel

movements per day

Acne Food allergies

Difficulty gaining weight Gallstones / Gallbladder disease

Nausea Foul smelling stool

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Restless leg syndrome Intolerance to probiotic supplements

Have you ever had food poisoning? If yes, when? ____________________________

Do certain foods tend to aggravate these issues? Which foods/ issues?

Do you suspect you have food allergies or sensitivities? If so, to what?

Past foreign travel? Where? __________________ When? __________________________

Where? __________________ When? __________________________

Where? __________________ When? __________________________

When was the last time you were on antibiotics? ____________________________________________

What were they prescribed for? __________________________________________________________

BLOOD SUGAR BALANCE

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Crave sweets during the day Heart palpitations if meal is skipped

Irritable if meal is skipped Headache, lightheaded or dizzy if

meal is skipped

Rely on coffee or soda in the

morning or to get through the

afternoon

Eating relieves fatigue

Feel shaky, jittery or have tremors Agitated, easily upset, nervous

Poor memory, forgetful Blurred vision

Wake at night, difficult to fall back

asleep

Have to eat during the night

Fatigue after meals Eating sweets does not relieve sugar

cravings

Crave sweets after meals Waist girth is equal to or larger than

hip girth

Frequent urination Increased thirst

Always hungry Difficulty losing weight

Excessively weak for no reason Get sleepy or drowsy after lunch

NUTRIENT DEFICIENCY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Bruise easily Cannot recall dreams

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Numbness in hands or feet Muscle cramping while at rest or

sleep

Strong light irritates eyes Crave chocolate

Anemia White spots on fingernails

Reduced sense of taste and/ or smell Susceptible to colds, infections

MOUTH HEALTH & HSTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Canker sores Cold sores

Gum disease/ infections Bleeding gums

Root canals

Do you floss regularly? ______________

Have your wisdom teeth been taken out? _______ Have any other teeth been extracted? __________

HEAD / FACE HEALTH & HSTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Post nasal drip Hair loss

Dry eyes Watery eyes

Dark circles under eyes Eye twitches

Ear infections Night blindness

Glaucoma Cataracts

Vertigo

CARDIOVASCULAR HEALTH & HISTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

High blood pressure Low blood pressure

Arrhythmias Palpitations

Murmurs Edema

Chest pain Atherosclerosis

URINARY TRACT HEALTH & HISTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Incontinence Pain with urination

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Kidney stones Urinary tract infections

Discharge / blood in urine Urgency

Foul smelling urine Dark colored urine

NERVOUS SYSTEM & HISTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Carpal tunnel Seizures

Tingling or numbness Fainting

ADRENAL FUNCTION

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Cannot stay asleep Cannot fall asleep

Slow starter in the morning Afternoon fatigue

Get dizzy when standing up quickly Afternoon headaches

Weak and/ or ridged fingernails Low blood pressure

Slow recovery after having a cold Poor circulation

Susceptible to respiratory

(bronchitis) or digestive infections

Difficulty holding chiropractic

adjustments

Cravings for salt Perspire easily

Under a lot of stress often Weight gain when stressed

Wake up tired after 6+ hours of sleep Hot flashes

Low sex drive Nervous/ anxious

Ankle, foot or low back pain Cry easily

Frequent urination

THYROID FUNCTION

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Tired, sluggish, fatigued Cold hands, feet, body

Trouble waking up in the morning Weight gain even with low calorie

diet

Difficulty losing weight Constipation, infrequent BMs

Depression, lack of motivation Morning headaches that wear off

during the day

Thinning of hair on outer eyebrows Hair loss or thinning of hair on scalp,

face or genitals

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Dry skin and scalp Mental sluggishness

Ringing in ears or noises in head Impaired hearing

Fast pulse even at rest Nervous, emotional, anxious

Insomnia Night sweats

Difficulty gaining weight Intolerant of high temperatures

FEMALE REPRODUCTION HEALTH & HISTORY

Describe your menstrual cycle:

Light/ or heavy ____________________________________________

How many days ___________________________________________

Cramping ________________________________________________

Clotting __________________________________________________

PMS _____________________________________________________

What do you use to relieve these symptoms? ______________________ Does it help? ____________

Are you sexually active? ___________

If so, what method of birth control do you use? ___________________________________________

List types of birth control used in the past:

__________________________ Used for how long? __________________________________________

__________________________ Used for how long? __________________________________________

How many times pregnant?__________ How many children? ________ Miscarriages? _____________

Type of delivery: vaginal caesarean

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Pain with intercourse Vaginitis / abnormal discharge

Abnormal pap smear Abnormal mammogram

Endometriosis PCOS

Breast cysts Fibroids

Menopausal ? Since what age? ______________ Use of replacement hormones?

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MALE REPRODUCTION HEALTH & HISTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Hernia Prostate inflammation/ BPH

Erectile dysfunction Difficulty urinating – reduced flow or

pain

EMOTIONAL HEALTH & HISTORY

Rank: 0 – least/ never; 1 – mild/ sometimes; 2 – moderate/ often; 3 – severe/almost always:

Depression Anger

Anxiety, panic attacks Irritability

Memory loss Brain fog

Difficulty concentrating Hyperactivity

Impulsiveness Feel overwhelmed

FAMILY HEALTH HISTORY

Has anyone in your family (including parents, grandparents, siblings, and children) experienced any of

the following illnesses/ conditions?

Condition Which family member? Condition Which family member?

Heart Disease Thyroid disorder

High blood pressure Autoimmune disorder

Heart Attack Arthritis

Stroke Osteoporosis

High cholesterol Alzheimer’s

Diabetes Dementia

Asthma Mental illness

Cancer Alcoholism

Depression Drug addiction

Food allergies Eating disorder

DIET AND EATING HABITS How many meals per day do you eat? _____________________________________________________

Do you follow any specific food guidelines (ie: vegan, vegetarian, gluten-free, Paleo, etc.)?

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4 Day Diet Journal (please include a weekend day if possible)

Breakfast Lunch Dinner Snacks/

Beverages

Day 1

Day 2

Day 3

Day 4

What are some of your favorite foods? ____________________________________________________

What are some of your least favorite foods? ________________________________________________

Which foods do you crave? ______________________________________________________________

Do you crave sweets? _______________ How often? ____________________ When? ______________

Do you consider yourself a fast or slow eater? __________________________

What do you drink during the day? _______________________________________________________

How many glasses (or ounces) of water each day? _________________________

How much alcohol do you consume during an average week? (# of beers/ glasses of wine or cocktails)

_____________________________________________________

Do you drink coffee? ____________ How many cups per day? _____________

Do you drink soda? ____________ How many per day/ per week? _____________

How often do you cook at home? _________________________________________________________

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Do you use a microwave to cook? ___________________

Do you like to cook? ______________________________

How often do you eat at restaurants or take-out per week? _________

Which places do you frequent? ___________________________________________________________

How often do you grocery shop? Once a week Twice a week More frequently

Where do you usually eat? (ex: at table, in front of TV, at desk at work ) _________________________

What is your idea of a healthy meal? ______________________________________________________

What does an unhealthy meal, one that doesn’t make you feel good, look like?

_____________________________________________________________________________________

POTENTIAL TOXIN EXPOSURE

Have you been exposed to any toxins that you’re aware of? ___________________________________

Have you ever lived near a manufacturing plant, farm or industrial area? ________________________

Have you ever worked on a farm or in a manufacturing plant? _________________________________

Have you ever lived in a home that had mold or water damage? _______________________________

Have you ever worked in a building that had mold, or water damage? ___________________________

Do you have (or did you have) mercury (silver) fillings in your teeth? ____________________________

Did you grow up in a house built before 1976 that may have had lead paint? _____________________

Do you use solvents or paints in your work or hobbies? _______________________________________

Does your home have new carpet, new paint or new furniture? ________________________________

Do you sleep on a new mattress? ________________________

Do you live in a brand-new home? _______________________ What year was it built? _____________

Do you have a strong reaction to smells? __________________

Are you very sensitive to medications and/ or caffeine? _________________________

Do you use pesticides, herbicides or cleaning chemicals in your house? __________________________

Do you travel often or have you worked in the airline industry? ________________________________

Do you swim in a chlorinated pool often? __________________________________________________

What type of water do you drink - well, tap, filtered or spring/ bottled water? ___________________

Did you receive all scheduled vaccinations as a child? ________________________________________

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Have you recently received any vaccinations (for international travel or flu shot, etc.)? _____________

Do you use nicotine? _____________________ If so, what type? _______________________________

Have you used nicotine in the past? _________ What type? _________ For how long? _____________

Are you often exposed to second hand smoke? _____________________________________________

Do you use any recreational drugs? _________ What types? ____________How often? ____________

Did have a habit of using drugs in the past? If so, which ones? _________________________________

LIFESTYLE & MOVEMENT

What is your stress level from 1 – 10 (1 being the lowest, 10 being the highest)

What are your stressors? ________________________________________________________________

How do you manage? __________________________________________________________________

Have you experienced a major stress in the past, such as trauma, abuse, divorce, loss of a loved one or

pet, care taking an ill family member or friend, difficult relationship, etc.?

How many hours per night do you sleep? _________ Do you wake up feeling refreshed? ___________

Do you fall asleep easily? _______________________ Do you wake up in the night? _______________

Do you frequently have insomnia? _______________ How many nights per week? ________________

Are you tired throughout the day? _______________ When? __________________________________

How often do you exercise per week? _____________ For how many minutes? ___________________

What type(s) of exercise? _______________________________________________________________

Do you enjoy exercising? __________________ Do you feel like you’re in good shape? ____________

What are your hobbies and past times? ____________________________________________________

Are you happy with your life? ____________

If not, what would you change? __________________________________________________________

What challenges do you face in order to create that happiness?

On a scale of 1 – 10 (10 being the highest) how committed are you to your goals?

On a scale of 1 – 10 (10 being the highest) how willing are you to change your diet and eating

habits?

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What else would you like to share?

Thank you for taking this time! This thorough information will help me understand your health history, past progress and current challenges so that, together, we can create a plan to reach

your goals. Nutrition Therapy is a client centered approach; with your commitment, enthusiasm and participation we will create solutions. I promise to provide education and support as you embark on this journey to greater health through proactive changes in diet and lifestyle. I am

grateful for this opportunity to work with you.

Jen Marshall, CNT

Be Balanced Healing, LLC

350 Broadway, Suite #200

Boulder, CO 80305

303-872-9695

support@bebalancedhealing.com

www.bebalancedhealing.com