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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