Holistic Nutrition

Intake Form

Name

Age

Sex

Address

Occupation

Who were you referred by?

If self referred, how did you hear about me?

Are you working with any other Brightside Integrated Health practitioners?

If so, would you like us to collaborate?

Yes No thanks

What are your nutritional goals?

Any allergies? If so, please list:

Any medications or supplements? If so, please list:

Do you have any medical conditions? If so, please list:

How is your digestion? (i.e. gas, pain, bloating)

How often do you have bowel movements?

Are your bowel movements hard, loose, contain undigested food?

How is your energy level?

When do you have the most energy?

When do you have the least energy?

How many hours of sleep do you get at night?

What time do you wake up/go to sleep?

What activities do you enjoy?

How many meals do you eat per day?

How many snacks do you eat per day?

How many alcoholic drinks a week?

What are your favourite foods?

Do you eat at fast food restaurants? Which ones?

Is there anything else you would like me to know?

Confidentiality & Acknowledgement

All personal information is completely confidential and remains with Lauren Brady-MacAulay, RHN, at Brightside Integrated Health. Information can be shared with other health practitioners, only at the client’s request, with a signed release of information form.

My goal is to help you to optimize your nutrition, so that you feel great and perform at your best. I make practical suggestions that are doable for clients and their families. I subscribe to a plant-based (not necessarily vegetarian), whole foods way of eating, which is beneficial for most people.

RHNs are not medical doctors, and do not provide medical diagnostic or treatment procedures. My services are at all times restricted to consultation regarding nutrition intended to support general good health and do not involve any act for which a medical license is required.

For more information about Registered Holistic Nutritionists, including our Scope of Practice and Code of Conduct, please click here.

By submitting this form, I acknowledge that I have read, understand, and agree to the above.

Holistic Nutrition

Confidentiality & Acknowledgement

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