Consultations are available with our Naturopath. Call or message or email Shelly Meier to schedule your appointment. Initial wellness consultations are $75. Includes a complimentary Bach flower remedy for emotional balancing. You may copy and print the intake form below, along with a Bach flower intake form and email a completed copy for online or Zoom consultations.
NUTRITION OUTLET WELLNESS INTAKE
Information Sheet
Name___________________________________________________ Phone _________________________________ Address _________________________________________________ Other Phone _______________________________ City ____________________________________________________ State/Zip__________________________________ Email _____________________________________
Relief from what symptoms? __________________________________________________________
How much movement/exercise weekly? ___________________________
What type of activity? ________________________
How many ounces of water do you drink daily? _________________ Type? RO Tap Spring Distilled
Which meals eaten daily? Breakfast Lunch Supper
How many bowel eliminations per day? ____ Color/consistency? ______________________________________
Urinary?______ Color? __________________________________
How many digestive enzymes daily? ________ How many breathing exercises daily? ___________
How much of the following do you consume? (1D = once daily, 3M = 3 times monthly)
Soda pop _________ Coffee ________ Smoking ___________ Alcoholic Bev __________ Fast food _________
Milk___________ White Flour _________ Sugar usage ___________ Raw fruit__________ Meat __________
Raw Veggies ________ Whole Grains __________
Comment on specifics of the above. (Diet soda? Decaf coffee? Red wine? Raw milk? et al….) ______________________
__________________________________________________________________________________________________
What types of food do you crave? Salty Chocolate Sweets Breads Other ____________________________
What are your favorite foods? __________________________________________________________________________
How much daily energy (1 = lowest energy level; 10 = highest energy level) do you have? __________________________
Any surgeries? Yes No If Yes, what and when? ____________________________________________ __________________________________________________________________________________________________
How many hours of TV do you watch daily? __________________
How many hours of “you time” do you spend each day? (prayer, meditation, naps, church, reading, study, etc.) __________________________________
How many hours a week do you spend with family/friends?______ Social? ___________ Obligation? __________
How many hours of sleep do you get each night? _______________ How many hours do you need? ________________
Prescription meds? Yes No If Yes, what/why/how long? ________________________________________________ _________________________________________________________________________________________________
Who referred you for your appointment today? _______________________________________________________
I understand that I am here to learn about food choices, lifestyle and natural health practices, and that I will be offered information about food, nutritional supplements, herbs and homeopathy, based on sound scientifically-supported study. I have come of my own free will and acknowledge that (printed name)___________________________________, (signature)____________________________, will offer assessments based on formal training in natural health, and holistic ministry.
I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnoses or treatment procedures.
I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies, or on a mission of entrapment or investigation.
The services performed here are at all times restricted to consultation on matters intended for the maintenance of the best possible state of natural health and stewardship of the body, and do not involve the diagnosing, treatment or prescribing of remedies for disease.
Signature________________________________________________ Date _____________________________________
Symptoms, Medical Diagnoses (by a licensed medical practitioner) and/or Areas of Concern:
(circle or underline all that apply)
Acne Circulation Hiatal Hernia Pneumonia
ADD/ADHD Cold - Common Hives Polyps
Adrenal Glands Cold - Temperature Hormones Pregnancy
Allergies Colic Hyperactive Prostate
Alzheimer’s Disease Colon Hypertension Psoriasis
Anemia Constipation Hyperthyroidism Rash
Anger Cough Hypoglycemia Reproductive
Anxiety Cravings Impotence Respiratory
Appetite Dandruff Incontinence Rheumatism
Arteriosclerosis Depression Indigestion Ringworm
Arthritis Diabetes Insomnia Seizures
Asthma Diarrhea Joint Pain Shingles
Back Pain Digestion Kidney Issues Sinus
Bad Breath Dizzy Spells Kidney Stones Skin Issues
Bed Wetting Ear Infection Laryngitis Snoring
Bell’s Palsy Ear Ringing Leprosy Sore Throat
Bites Edema Leukemia Stomach
Bladder Emphysema Liver Stress
Blood Pressure - High Epilepsy Lung Issues Stroke
Blood Pressure - Low Eyesight Lupus Sty
Boils Fatigue Lymph Glands Teething
Bones Fever Menopause Tennis Elbow
Breathing Flu Menstrual Cramps Tonsillitis
Bronchitis Gallstones Migraines Tumors
Bruises Gangrene Mononucleosis Ulcers
Burns Gas Mucous Urinary Infections
Cancer Gout Nails Varicose Veins
Candida Gums Nausea Vertigo
Canker Sores Hair Issues Nervousness Weight - Overweight
Carpal Tunnel Headache Nose Bleeds Weight - Underweight
Cataracts Heart Issues Parasites Yeast Infections
Chest Congestion Heartburn Parkinson’s Disease OTHER: ______________
Chest Pain Hemorrhoids Perspiration _____________________
Cholesterol Herpes PMS _____________________
NOTES:
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