Intake Form Client Intake Form Privacy Policy Order Number First Name * Last Name * Street * Province * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Date of Birth: * Phone Number * City * Postal Code * Email Address * Occupation * Hours Per Week Family Health History * Do you have pets? * What cardio do you do? How often/duration? * What weight training do you do? How often/duration? * What relaxation exercise do you do? How often/duration? * Do you experience digestive difficulties? Ex: bloating, indigestion, gas, constipation. Describe. * Do you have a bowel movement every day? If so, how many per day? * List any known food or environmental allergies and intolerances. ie: hay fever, grass, lactose intolerance, etc Provide complete details on your entire health history and be as specific as possible * Try to remember antibiotic courses, recurring infections, surgeries, oral health, diagnoses, history of medications, etc List all supplementation you are taking: This can be herbs, teas, tinctures, vitamins, minerals, protein powders, greens powders, etc. Describe any health issues or problems you are currently experiencing. Specify your main concern: Is there anything in your life that will get in the way of following a treatment plan? Coffee? * Yes No Black Tea? * Yes No Carbonated Beverages? * Yes No Alcohol? * Yes No List 3 foods you cannot live without * Provide any other information you think may be relevant to your diet. How much water do you drink per day? * Water Source? * Tap Water Filtered Water Purified Water Reverse Osmosis Bottled Water Other How many fruit per day? * How many vegetables do you eat per day? * Do you buy organic? * Yes No When possible What do you wash non-organic produce in? * Vegetable rinse Peroxide Water None Other Is your occupation stressful? Describe. * Are there any stressful relationships with colleagues or management? * Are there stressful relationships with family members? * Provide any further information that is relevant to emotional life. * Which of the following do you use? * Microwave Electric Blanket Water Bed Smart Watch None of the above How often do you travel by plane? * Are you exposed to fluorescent lighting at home or at work? * Yes No Do you use a computer at home or at work? * Yes No Do you use a cell phone? * Yes No List 3 health goals you wish to attain for yourself: * By submitting this form, I hereby attest the following: That I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for any government agency on a mission of entrapment. I fully understand that Kayla Roy is not a medical doctor and I am not here for medical diagnostic or treatment procedures. The services performed by Kayla Roy are at all times restricted to the consultation on the subject of nutrition intended for building wellness and do not involve the diagnosing, prognosticating, treating or prescribing remedies for the treatment of disease, or any act which a medical license or medical authorization is required. This agreement is being signed voluntarily and not under duress of any kind. * I have read and agree to the terms stated above. Date *
