Welcome to the Well!

Help us get to know you a little better! Kindly fill out the New Client Form below.

This form must be completed only AFTER scheduling your appointment with our Client Advocate team. If you have not yet scheduled your appointment, please contact us!

Personal Information

Name

Email Address

Mailing Address

Street Address

City

State

Zip Code

Main Phone Number

Secondary Phone Number

Date of Birth

Place of Birth

Age

Gender

Height
feet, inches

Current Weight
pounds

Would you like your weight to be different?
YesNo

If so, what would you like your weight to be?
pounds

Occupation

How many hours do you work per week?

Marital Status

Do you have any children?
YesNo

Blood Type (if known)


Personal Health and Lifestyle

Describe the symptoms you are currently experiencing:

What would you like to accomplish/gain from this consultation?

Do you sleep well?

Do you wake up during the night?

If so, at what times?

What time do you generally go to bed?

What time do you generally wake up?

How do you feel when you wake up?

Do you drink caffeinated drinks?
YesNo

If so, how much and how often?

Do you currently smoke?
YesNo

If so, how much and how often?

Have you ever smoked?
YesNo

If you have quit smoking, why, how, and when did you quit?

Do you drink alcohol?
YesNo

If so, how much and how often?

Do you drink soda (diet or regular)?
YesNo

If so, how much and how often?

What role does exercise play in your life?

How much water do you drink per day?

Please list any doctor-recommended or prescribed medications, creams, supplements, or vitamins you are currently taking (for any reason). Also include any over-the-counter products you are currently taking:

Do you have any known allergies to medications or herbs?
YesNo

If so, please list all below:

Are you currently under a practitioner's care for a specific health issue?
YesNo

If so, what treatments are you undergoing?

Please list any surgeries, accidents, injuries, or childhood diseases you have had, along with the type and approximate date:

What are your current eating/drinking habits?

Breakfast

Lunch

Dinner

Snacks

Drinks

What were your eating habits like as a child? List types of foods:

What percentage of your food is home cooked?

How often do you eat out?

What are the three worst foods you eat each week?

What are the three healthiest foods you eat each week?

Do you crave sugar?

Do you crave salt?

Do you feel tired, bloated, and/or gassy after meals?

Do you experience constipation or diarrhea?

Do you feel excessively hungry?

Do you have a poor appetite?

Please list any known food allergies and/or intolerances:

Within the last two years, have you been tested for any of the following hormones?

DHEA YesNo

Cortisol YesNo

Testosterone YesNo

Estrogen YesNo

Progesterone YesNo

Were your hormone levels normal? If not, please explain:

Have you had any previous colon cleansing sessions with a certified colon therapist?
YesNo

If so, when, and how many?


Family Health History

List anyone in your family who has suffered from...

Diabetes

Heart Disease

Kidney Disease

Asthma

Arthritis

Gallbladder Disease

Stomach/Intestinal disorders

Cancer (include type of cancer)

Other

Mother's Age

If your mother is no longer living, what did she die from?

Father's Age

If your father is no longer living, what did he die from?

Maternal Grandmother's Age

If your grandmother is no longer living, what did she die from?

Maternal Grandfather's Age

If your grandfather is no longer living, what did he die from?

Paternal Grandmother's Age

If your grandmother is no longer living, what did she die from?

Paternal Grandfather's Age

If your grandfather is no longer living, what did he die from?


THIS SECTION IS FOR WOMEN ONLY

How old were you when you got your first period?

Are your periods regular?

How frequent are your periods?

How many days is your flow?

How many pregnancies have you had?

Do you experience PMS

If so, is it mild or severe?

Are you peri-menopausal?
YesNoUnsure

If so, when did this change first occur?

Are you menopausal?
YesNoUnsure

If so, when was your last period?

List your symptoms of peri/menopause:

How many children have you delivered, and how were they born (vaginally or by cesarean)?

Were there complications associated with these births? If so, please explain:

Did you receive antibiotics during labor?
YesNoN/A

Have you ever had a miscarriage or an abortion?
YesNo

If so, how many?


Please check if any of the following conditions currently apply to you:

GROUP A
Absence of PeriodAdrenal FatigueEndometriosisFatigueFibrocystic BreastsGenital Itch/DischargeHormonal ImbalancesHyperthyroidismHysterectomyImpotenceInfertilityInsomniaIrregular Pap TestsMenopauseMenstrual CrampsPMSPregnancyProstate ProblemsReproductive IssuesRestlessnessVaginitisYeast Infections

GROUP B
AcneArthritisBack PainBitesBoilsBone ProblemsBruisesBurnsCarpal Tunnel SyndromeDandruffEczemaExcess SweatingGoutHair IssuesHivesJoint PainLeprosyMuscle PainNail IssuesPerspiration IssuesPsoriasisRashRheumatismRing WormSensitive SkinSensitive TeethShinglesSkin IssuesTeethingTennis Elbow

GROUP C
ADD/ADHDAlzheimer’s DiseaseAngerAnxietyApathyBell’s PalsyBlurred VisionCataractsConfusionDepressionEar DrainageEar InfectionEar RingingEarachesEpilepsyEyesight IssuesHyperactivityIrritabilityItchy EarsItchy or Red EyesLearning ProblemsMigrainesMood SwingsNervousnessNose BleedsParkinson’s DiseasePoor ConcentrationPoor MemorySeizuresStressStrokeStutteringStysTunnel VisionWatery Eyes

GROUP D
AllergiesAsthmaBad BreathBreathing ProblemsBronchitisChest CongestionChest PainChronic CoughCoughEmphysemaLaryngitisLung IssuesMucousPneumoniaRespiratory IssuesShortness of BreathSinus ProblemsSneezingSnoringSore ThroatStuffy NoseTonsilitis

GROUP E
AnemiaArteriosclerosisCancerCholesterol IssuesCirculation ProblemsCold (temperature)Dizzy SpellsEdemaFainting SpellsFeverFluFrequent IllnessGangreneHigh Blood PressureHypertensionIrregular HeartbeatsKidney FailureKidney InfectionKidney IssuesKidney StonesLeukemiaLiver IssuesLow Blood PressureLupusLymph ProblemsMononucleosisParasitesRapid HeartbeatSwelling of AnklesTumorsVaricose VeinsVertigo

GROUP F
Appetite IssuesBed WettingBelchingBinge EatingBladder ProblemsBloatingBurning UrinationCandidaCanker SoresColicColon ProblemsCompulsive EatingConstipationCravingsDiabetesDigestive IssuesEating DisorderGallstonesGasGum ProblemsHeartburnHemorrhoidsHiatal HerniaHypoglycemiaIncontinenceIndigestionNauseaPolypsRefluxStomach IssuesUlcersUrinary InfectionsWater RetentionWeight Issues


Please check below to indicate that you have read and understand that you cannot be seen for your Initial Consultation unless the following requirements are met:
-This New Client Form must be completed and submitted
-Nutritional Questionnaire must be completed (separate from this form)
-Your current medications and supplements must be brought to your appointment

I understand the requirements needed in order to be seen for my Initial Consultation

Thank you. Have a nice day!