Intake Form Name * First Name Last Name Email * Phone Number (###) ### #### How Often Do You Check Email? Place of Birth Birthdate MM DD YYYY Age Height Is weight a concern and if so how would you like it to be different? Social Information Relationship Status Where do you currently live? Do you have any children? What is your occupation? How many hours do you work per week? Health Information Please list your main health concerns: Any other goals or concerns? Any serious illnesses/hospitalizations/injuries? How is/was the health of your mother? How is/was the health of your father? How is your sleep? How many hours do you sleep? Do you wake up at night? Why? Any pain, stiffness or swelliing? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain Are your periods regular? women How frequent? women Painful or symptomatic? Please explain women Reached or approaching menopause? Please explain women Birth control history women Do you experience yeast infections or urinary tract infections? Please explain What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids What is your diet like these days? Breakfast? Lunch? Dinner? Snacks? Liquids? Do you cook? What percentage of your food is home-cooked? Where do you get the rest from? Do you crave sugar, coffee, cigarettes or have any major addictions? Medical Information Do you take any supplements or medications? Please list Any healers, helpers, or therapies with which you are involved? Please list What role do sports and exercise play in your life? Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Anything else you would like to share? How did you hear about Alex G Shearer Health? Digital Signature Thank you!