Intake Form – For the Love Of Mangoes

First Name

Last Name

Street

Province

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?