Client Information Name Click or tap here to enter text. Address Click or tap here to enter text. City Click or tap here to enter text. State Click or tap here to enter text. Zip Code Click or tap here to enter text. Phone (day) Click or tap here to enter text. Phone (cell) Click or tap here to enter text. Phone (night) Click or tap here to enter text. Email Click or tap here to enter text. Referred by Click or tap here to enter text. Statistics Age Click or tap here to enter text. Birth Date Click or tap here to enter text. Gender Click or tap here to enter text. Height Click or tap here to enter text. Blood Type Click or tap here to enter text. Current Weight Click or tap here to enter text. Ideal Weight Click or tap here to enter text. Weight One Year Ago Click or tap here to enter text. Birth Weight (if known) Click or tap here to enter text. Birth Order (please list ages of biological siblings) Click or tap here to enter text. Michele Law, INHC Inner Sage Healing Arts Center 1 Grove Street, Suite 103; Pittsford, NY 14534 (585) 383-8833
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Client Information
Name Click or tap here to enter text.
Address Click or tap here to enter text.
City Click or tap here to enter text. State Click or tap here to enter text. Zip Code Click or tap
here to enter text.
Phone (day) Click or tap here to enter text. Phone (cell) Click or tap here to enter text.
Phone (night) Click or tap here to enter text.
Email Click or tap here to enter text.
Referred by Click or tap here to enter text.
Statistics
Age Click or tap here to enter text. Birth Date Click or tap here to enter text.
Gender Click or tap here to enter text.
Height Click or tap here to enter text.
Blood Type Click or tap here to enter text.
Current Weight Click or tap here to enter text. Ideal Weight Click or tap here to enter text.
Weight One Year Ago Click or tap here to enter text.
Birth Weight (if known) Click or tap here to enter text.
Birth Order (please list ages of biological siblings) Click or tap here to enter text.
Family/Living Situation Click or tap here to enter text.
Children Click or tap here to enter text.
Occupation Click or tap here to enter text.
Exercise/Recreation Click or tap here to enter text.
Michele Law, INHCInner Sage Healing Arts Center
1 Grove Street, Suite 103; Pittsford, NY 14534(585) 383-8833
History
1. Have you lived or traveled outside of the United States? If so, when and where? Click or tap
here to enter text.
2. Have you or your family recently experienced any major life changes? If so, please comment:
Click or tap here to enter text.
3. Have you experienced any major losses in life? If so, please comment: Click or tap here to enter
text.
4. How much time have you had to take off from work or school in the last year?
☐ 0 to 2 days☐ 3 to 14 days☐ more than 15 days
Health Concerns
5. What are your main health concerns? (Describe in detail, including the severity of the
symptoms): Click or tap here to enter text.
6. When did you first experience these concerns? Click or tap here to enter text.
7. How have you dealt with these concerns in the past? Click or tap here to enter text.
8. Have you experienced any success with these approaches? Click or tap here to enter text.
9. What other heath practitioners are you currently seeing? List name, specialty, and phone
number. Click or tap here to enter text.
10. Please list the date and description of any surgical procedures you have had, including breast
reduction or augmentation. Click or tap here to enter text.
11. How often did you take antibiotics in infancy/childhood? Click or tap here to enter text.
12. How often have you taken antibiotics as a teen? Click or tap here to enter text.
13. How often have you taken antibiotics as an adult? Click or tap here to enter text.
14. List any medicine you are currently taking: Click or tap here to enter text.
15. List all vitamins, minerals, herbs and nutritional supplements you are now taking: Click or tap
here to enter text.
Michele Law, INHCInner Sage Healing Arts Center
1 Grove Street, Suite 103; Pittsford, NY 14534(585) 383-8833
16. Have any other family members had similar problems? (Describe): Click or tap here to enter
text.
Nutritional Status
17. Are there any foods that you avoid because of the way they make you feel? If yes, please name
the food and the symptoms: Click or tap here to enter text.
18. Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? If so,
please explain: Click or tap here to enter text.
19. Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle
aches, sinus congestion, etc? If so, please explain: Click or tap here to enter text.
20. Are there foods that you crave? If so, please explain: Click or tap here to enter text.
21. Describe your diet at the onset of your health concerns: Click or tap here to enter text.
22. Do you have any known food allergies or sensitivities? Click or tap here to enter text.
23. Which of the following foods do you consume regularly?
☐ soda ☐ diet soda ☐ refined sugar☐ alcohol ☐ coffee
☐ gluten free ☐ Other (please describe): Click or tap here to enter text.
25. What percentage of your meals are home cooked?
☐10 ☐20 ☐30 ☐40 ☐50 ☐60 ☐70 ☐80 ☐90 ☐100
26. Is there anything else we should know about your current diet, history or relationship to food?
Click or tap here to enter text.
Intestinal StatusMichele Law, INHC
Inner Sage Healing Arts Center1 Grove Street, Suite 103; Pittsford, NY 14534
(585) 383-8833
27. Bowel Movement Frequency
☐ 1-3 times per day
☐ more than 3 times per day
☐ not regularly every day
28. Bowel Movement Consistency
☐soft and well-formed ☐thin, long or narrow ☐often float
☐small and hard ☐difficult to pass ☐loose but not watery
☐diarrhea ☐alternating between hard and lose
29. Bowel Movement Color
☐medium brown ☐very dark or black ☐greenish ☐variable
☐yellow, light brown ☐chalky colored ☐blood is visible ☐greasy, slimy
30. Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Click or tap here to enter text.
31. Have you ever had food poisoning? If yes, please describe in detail, including 1) Where you
were, 2) what did you treat it with and 3) if you feel like you fully recovered from it: Click or tap
here to enter text.
Medical Status
32. Please identify any current or past conditions and add a date for when the condition appeared. In the space below each list, please briefly describe your symptoms, chosen treatment(s), and dates.
GASTROINTESTINAL
Past Now Date
☐ ☐ __________ Gut Infections
☐ ☐ __________ Dysbiosis
☐ ☐ __________ Leaky Gut
☐ ☐ __________ Food Allergies, intolerances or reactions
☐ ☐ __________ Irritable Bowel Syndrome
☐ ☐ __________ Crohn’s Disease
☐ ☐ __________ Ulcerative Colitis
Michele Law, INHCInner Sage Healing Arts Center
1 Grove Street, Suite 103; Pittsford, NY 14534(585) 383-8833
☐ ☐ __________ Gastritis or Peptic Ulcer Disease
☐ ☐ __________ GERD (reflux or heartburn)
☐ ☐ __________ Celiac Disease
☐ ☐ __________ Small Intestinal Bacterial Overgrowth (SIBO)
☐ ☐ __________ Gall Stones
☐ ☐ __________ Known absorption or assimilation issues
☐ ☐ __________ Other Click or tap here to enter text.
Please briefly describe your symptoms, chosen treatment(s) and dates: Click or tap here to enter text.
CARDIOVASCULAR
Past Now Date
☐ ☐ __________ Heart Attack
☐ ☐ __________ Heart Disease
☐ ☐ __________ Stroke
☐ ☐ __________ Elevated Cholesterol
☐ ☐ __________ Arrhythmia (irregular heartbeat)
☐ ☐ __________ Hypertension (high blood pressure)
☐ ☐ __________ Rheumatic Fever
☐ ☐ __________ Mitral Valve Prolapse
☐ ☐ __________ Other Click or tap here to enter text.
Please briefly describe your symptoms, chosen treatment(s), and dates: Click or tap here to enter text.
HORMONES/METABOLIC
Past Now Date
☐ ☐ __________ Type 1 Diabetes
Michele Law, INHCInner Sage Healing Arts Center
1 Grove Street, Suite 103; Pittsford, NY 14534(585) 383-8833