Larissa Ness

Integrative Health Practitioner

Health Intake Form

Name Email Phone Time Zone Address City State Zip Country Birth Place Birth Date Age Height (feet, inches) Weight (lbs) Gender Occupation

Describe Problem(s) What treatments have you tried? Has anything been successful? Have you lived or traveled outside of the United States? If so, when and where? How much time have you lost from work or school in the past year? Please list any allergies or intolerances: (food or environmental) Do you smoke? List past medical and surgical history: List previous hospitalizations: How often have you taken antibiotics? (as a child and adult) How often have you have taken oral steroids?
(e.g., Cortisone, Prednisone, etc.) What medications are you taking now? (including birth control/hormones) List all vitamins, minerals, and other nutritional supplements that you are taking now. What is your typical daily diet: (List typical meals and snacks) How much of the following do you consume each week? (Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert) Is there anything special about your diet that we should know? Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? How many bowel movements (BM) do you have per day?
Example: 0-1, 1-2, 3 or more Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? Do you have intestinal gas? If so, when? How many times per week do you drink alcohol? Do you have mercury amalgam fillings in your teeth? If so, how many? Do you have any artificial joints or implants? If so, which ones? Have you, to your knowledge, been exposed to toxic metals in your job or at home? How would you rate your current level of stress? Women: Are you pregnant or breastfeeding? Women: If you have a cycle, how long is it and is it regular? Women: Do you have any problematic symptoms related to your cycle? Do you exercise regularly? If so, how many times a week? What type of exercise is it? Do you struggle with insomnia or interrupted sleep? Do your parents or siblings have (or had) any health issues? If so, please explain: Please add any other information you feel is important:

Today's Date Referred By (If working with an IHP coach, please list name)