Holistic Consultation Intake Form

Holistic Consultation Questionnaire

Please set aside a minimum of 30 minutes to complete this form. We kindly ask that you respond to the following questions as thoroughly as you feel comfortable. The information you provide enables us to conduct a comprehensive clinical assessment and to develop a realistic, personalized plan to support you in achieving your health goals. Questions related to areas such as relationship status, religious beliefs, and other personal factors offer valuable context that helps us establish a respectful and effective therapeutic partnership. However, please feel free to omit any questions you prefer not to answer. Your comfort and privacy are of utmost importance to us, and we appreciate your time and trust. Any questions please email me at drmels@mail.com

Who is filling out this form for the client? *MyselfParentGuardian

Relationship to client? *Put N/A if you are filling out this form for yourself, the client.0 / 25

Client Information

Prefix

First Name *

Middle Name

Last Name *

Pronouns *

Preferred Nickname *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Email Address *

Confirm Email Address *

Service Type *30 Minute Consultation1 Hour Consultation

Today's Date *

Demographics

Sex *MaleFemale

Ethnicity *

Height *

Race *

Current Weight *

Highest Adult Weight *N/A if client is not an adult

When was this weight? *

Personal Information

Highest Level of Education Completed *

Degree

Occupation *

What are your current interests or passions?

Relationship Information *

Religion

With whom (persons or animals) do you share your home?

What types of health practitioners are you currently working with? *N/A if you are not currently working with anyone.

What are your concerns and reasons for this consultation? *0 / 100

Medical Information

What health concerns did you experience as a child? *

What health concerns have you experienced as an adult? *

Has your doctor diagnosed you with a medical condition(s)? *YesNo

Official diagnosis?0 / 100

Are you part of a recovery program? *YesNo

Do you have any allergies to foods, medications, chemicals, and/or other environmental substances? *YesNo

What, if any, surgeries/operations have you undergone, and when? *Write the surgery/operation followed by the date. Separate each surgery with a semicolon. E.g. Knee surgery July 4, 2025; Heart surgery April 8, 20250 / 100

Any important information surrounding these surgeries or operations?0 / 200

Have you ever been hospitalized for reasons other than surgeries/operations? *YesNo

Have you ever had a major chemical exposure? *YesNo

Have you lived or traveled outside of the U.S. and Canada? *If no, put N/A for the next question.YesNo

Where and when have you lived or traveled outside of the U.S. and Canada? *Write where followed by the date range. Separate each location with a semicolon. E.g. U.S. 2021-current; Canada 2018-2021; Japan 2015-20180 / 100

Is there anything that surfaced during a recent medical test, lab work, or doctor’s visit that you would like to report? *If no, put N/A for the next question.YesNo

Information that surfaced during a recent medical test, lab work, or doctor’s visit you would like to report. *0 / 200

Family History

Maternal grandfather's current state of health? If deceased, please state cause of death. *0 / 50

Maternal grandmother's current state of health? If deceased, please state cause of death. *0 / 50

Mother's current state of health? If deceased, please state cause of death. *0 / 50

Paternal grandfather's current state of health? If deceased, please state cause of death. *0 / 50

Paternal grandmother's current state of health? If deceased, please state cause of death. *0 / 50

Father's current state of health? If deceased, please state cause of death. *0 / 50

Brother's current state of health? If deceased, please state cause of death. *0 / 50

Sister's current state of health? If deceased, please state cause of death. *0 / 50

Any important information to note about family history?0 / 100

Medications and Supplements

Are you currently taking any medications? *If no, put N/A for the next question.YesNo

Current Medications (over-the-counter and prescription): *Please read carefully: Copy and paste this format (1 Name-, Dosage-, Frequency-, How long-, Reason-, Helpful?-;). Essentially, write the medication name, dosage, frequency, how long you have been taking it, the reason for taking it, and whether or not it has been helpful followed by a dash. Write a semicolon after completing the information for each medication. E.g. 1 Name- Captopril, dosage- 12.5 mg, frequency- 3x a day, how long- 10 months, reason- high blood pressure; helpful?-yes; 2 Name- Amoxicillin, dosage- 500 mg, frequency- 3x/daily or every 8 hours, how long- 7 days, reason- to treat sinusitis, helpful?-somewhat;0 / 300

What medication have you taken in the past for a considerable amount of time and why? Was it helpful? Why or why not? *Put N/A if this does not apply to you.0 / 100

Are you currently taking any vitamins, minerals, herbs, or other dietary supplements? *If no, put N/A for the next question.YesNo

Current vitamins, minerals, herbs, or other dietary supplements: *Please read carefully: Copy and paste this format (1 Name-, Brand- Dosage-, Frequency-, How long-, Reason-, Helpful?-;). Essentially, write the name, brand, dosage, frequency, how long you have been taking it, the reason for taking it, and whether or not it has been helpful followed by a dash. Write a semicolon after completing the information for each. E.g. 1 Name- Vitamin D3, Brand- Nature Made, Dosage- 2000 IU, Frequency: Once daily, How long- 4 months, Reason-To support bone health and immune function, Helpful?-Yes; 2 Name- Magnesium Glycinate, Brand- Doctor's Best, Dosage- 200 mg, Frequency- Once daily, in the evening, How long- 7 months, Reason- To reduce muscle tension, improve sleep, and support relaxation, Helpful?- Somewhat0 / 300

Pregnancies

Are you currently pregnant? *YesNo

Are you actively trying to conceive? *YesNo

Are you breastfeeding? *YesNo

Pregnancies—please include losses/terminations: *Please read carefully: Copy and paste this format (1 Year-, Term-, Length- Delivery-, Sex-, Complications/Other Important Information- ;). Essentially, write the year of pregnancy, term of the pregnancy (e.g. full term, preterm), length of pregnancy (e.g. 20 weeks, 39 weeks), delivery type (e.g. C-section, vaginal), sex of the baby, and any complications or important information to note. Write a semicolon after completing the information for each. E.g. 1 Year- 2020, Term- Full term, Length-39 weeks, Delivery- Vaginal, spontaneous labor, Sex- Female, Complications/Other Important Information- Mild preeclampsia managed with monitoring; healthy birth weight (7 lbs 2 oz)0 / 300

Stress

Indicate your stress levels on a scale of 1-10, with 1 being the lowest and 10 being the highest:

Work *0 / 100

Social/Family Situation *0 / 100

Current Health Status *0 / 100

Life in General *0 / 100

Do you feel that your current state of health is: *largely in your controlmildly in your controlneutrally in your controlmildly out of your controllargely out of your control

Do you believe you can make a difference in your current health status? *If no, put N/A for the next questions.YesNo

If yes, list what do you believe you can do to make a difference in your current health status? *0 / 50

If yes, list 1-2 key steps have you already taken: *0 / 50

Sleep

At what time are you typically in bed? *0 / 25

What time do you fall asleep? *0 / 25

Typical hours asleep: *0 / 25

Do you feel rested upon rising? *0 / 25

Number of times you awaken during the night: *0 / 25

Reason(s) why you wake during the night: *0 / 25

Lifestyle

Please use numeric values when describing the frequency. Note any important information for each category when necessary.

Socialization (Frequency and Comments) *Put N/A if this does not apply to you.0 / 25

Exercise (Frequency and Comments) *Put N/A if this does not apply to you.0 / 25

Sexual Activity (Frequency and Comments) *Put N/A if this does not apply to you.0 / 25

Self Care/Relaxation (Frequency and Comments) *Put N/A if this does not apply to you.0 / 25

Recreational drugs (Frequency and Comments) *Put N/A if this does not apply to you.0 / 25

Tobacco (Frequency, Type, and Comments) *Put N/A if this does not apply to you.0 / 25

Are you a smoker? *YesNo

Teeth Flossing (Frequency and Comments) *Put N/A if this does not apply to you.0 / 25

Diet

Please use numeric values when describing the frequency. Note any important information for each category when necessary.

What would you describe is your overall diet type? *Please include information if there are any belief systems affiliated with your diet.0 / 25

Do you have any allergies? If so, please list them. *0 / 25

Soda/Soft Drinks/Cold Drinks/Pop (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Are there any foods you cannot eat as a result of your belief system? *Put N/A if this does not apply to you.0 / 25

Alcohol (Frequency, Amount, and Type) *Put N/A if this does not apply to you.0 / 25

Caffeine (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

White Meat-Poultry/Pork (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Red Meat-Lamb/Beef (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fish (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Other Seafood (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Eggs (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Nuts and Seeds (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fruits-Fresh (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fruits-Canned (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fruits-Frozen (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fruits-Dry (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Vegetables-Fresh (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Vegetables-Canned (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Vegetables-Frozen (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Vegetables-Dry (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Dairy Products-Milk, Yogurt, Cheese, Butter (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Cooking oils (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Bread and Other Grains (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Soy Products (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fried Foods (Frequency and Type) *Put N/A if this does not apply to you.0 / 25

Fast, Convenience, and Processed Foods(Frequency and Type) *Put N/A if this does not apply to you.0 / 25

How many times each week do you eat breakfast at home vs. out? *Put N/A if this does not apply to you.0 / 25

How many times each week do you eat lunch at home vs. out? *Put N/A if this does not apply to you.0 / 25

How many times each week do you eat dinner at home vs. out? *Put N/A if this does not apply to you.0 / 25

Approximately how many ounces of water do you drink per day and type (Bottled, Filtered, Tap) *Put N/A if this does not apply to you.0 / 25

Moods

Please select all of the options that apply to you. Multiple options are available for selection.

Significant Life Events

Include illness, medical conditions, births, deaths, marriage, divorce, accidents, moves, jobs changes, miscarriages, and anything else you feel greatly impacted your life.

List major events of your life and the dates they occurred from MOST RECENT to LATEST. *Use this format: (1 Event: , Date: ;). Follow each with a semicolon for separation. E.g. 1 Event: Mom diagnosed with cancer, Date: 6/25/24; 2 Event: Cat died, Date: 2/1/18.0 / 300

Review of Body Systems

Please indicate any of the following items that you are currently experiencing or that is relevant to your current health. Please select all of the options that apply to you. Multiple options are available for selection.

HeadHeadacheMigraineSeizure

NoseDischargeBloodCongestion

Do you preform breast self-exams?YesNo

Age at onset of menses:0 / 25

Length of menstrual cycle in days0 / 25

Amount of bloodHeavyModerateLightNone

Do you expel blood clots during your cycle?Yes. A lotYes. A medium amountYes. A little bitNo. None

Number of bowel movements per day? *0 / 25

Does your stool typically float or sink? *0 / 25

Number of urinations per day *0 / 25

Symptom Questionnaire

Please indicate any of the following items that you are currently experiencing or that is relevant to your current health. Please select all of the options that apply to you. Multiple options are available for selection.

Hyperactive Upper GI Function—HyperchlorhydriaHeartburn or acid reflux symptomsStrong appetite, demanding hunger, excess salivationNausea in morningsAggravated by spice or sour, sour burps, sour smell

Small Intestine:Food allergies or sensitivities (wheat or grain, or dairy or other)Craving, addiction or binging of allergenic food(s)Pulse speeds up after eatingAirborne allergiesFrequent intake of allergenic food(s), strong attachment to allergenic foodsAbdominal bloating 1-2 hours after eatingCrohn’s disease, frequent sinus infection, migraines, asthmaExperience hives

Immune:Catch colds at the beginning of winterExperienced a mucus producing coughHistory of Epstein-Barr, mononucleosis (mono), herpes, shingles, chronic fatigue syndrome, hepatitis, or other chronic viral conditionsFrequent colds, flu or other infections (sinus, ear, bladder, skin, etc.)Never get sickHave food allergies or sensitivities

Cardiovascular/Circulatory:Aware of irregular or heavy breathingSigh frequently or “air hunger”Experience swelling of the ankles, especially at end of dayHave muscle cramps on exertionExperienced discomfort at high altitudesHave shortness of breath with moderate exertionBlush or face turns red for no reasonExperience a dull pain or tightness in chest and/or radiate into left arm, worse on exertion

Thank You For Completing This Form!

Please make sure that you complete the consent form, payment form, and any other requirements as indicated in an email sent following booking your consultation. Questions: email me at drmels@mail.com

Holistic Consultation Questionnaire

Client Information

Demographics

Personal Information

Medical Information

Family History

Medications and Supplements

Pregnancies

Stress

Indicate your stress levels on a scale of 1-10, with 1 being the lowest and 10 being the highest:

Sleep

Lifestyle

Please use numeric values when describing the frequency. Note any important information for each category when necessary.

Diet

Please use numeric values when describing the frequency. Note any important information for each category when necessary.

Moods

Please select all of the options that apply to you. Multiple options are available for selection.

Significant Life Events

Include illness, medical conditions, births, deaths, marriage, divorce, accidents, moves, jobs changes, miscarriages, and anything else you feel greatly impacted your life.

Review of Body Systems

Please indicate any of the following items that you are currently experiencing or that is relevant to your current health. Please select all of the options that apply to you. Multiple options are available for selection.

Symptom Questionnaire

Please indicate any of the following items that you are currently experiencing or that is relevant to your current health. Please select all of the options that apply to you. Multiple options are available for selection.

Thank You For Completing This Form!

Please make sure that you complete the consent form, payment form, and any other requirements as indicated in an email sent following booking your consultation. Questions: email me at drmels@mail.com

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