Client Intake Form

Are you currently under the care of a physician?

Yes

How many times have you had a course of antibiotics in your life?

5-10

>10

Are you or have you ever been a a cigarette, pipe, cigar smoker or chewed tobacco?

Yes

Do you have any known food allergies?

How would you rate your levels of satisfaction/happiness in the following areas, on a scale of 1-10, with

ten indicating an extremely high level of satisfaction/happiness?

What forms of movement/exercise do you enjoy/practice? (check all that apply)

On a scale of 0-10, where 0 is never/least and 10 is always/most, please rate the following:

Males only:

Menstruating Females only:

Menopausal Females only:

Which of these foods do you consume regularly (at least four times per week)?

Are you/have you ever been on on a specialized eating plan? (Check all that apply)

Rate on a scale of 0 (not willing) to 10 (very willing):

In order to improve your health, you are willing to:

I understand that the information provided on the relationship between nutrition, lifestyle and health is NOT meant to replace competent medical treatment for any health problems or conditions. Health education and medical care are complementary and integrative when properly delivered.

I choose to improve my health by assuming greater responsibility to reduce or eliminate behaviors that are not supportive of my desired lifestyle and outcome for my health.

I understand that I must provide a minimum of 48 hours of advanced notice before rescheduling or cancelling an appointment. A charge of $50.00 per hour of scheduled time will be assessed, based on the discretion of Dr. Enmark.

I understand that payment for all services is expected at the time of the appointment. We accept cash, check, and Venmo (@Michelle-Enmark).

We agree to work together to design and maintain an individualized health and wellness plan based on the gathered findings, practical skills, commitment to the desired outcome, and support.