health equations                    INTAKE FORM

Name _________________________________   Date______________   

Occupation______________________   Age_____   Sex_____   D.O.B.__________  

Blood Pressure________  Pulse____  Blood Type____  Height_____  Weight_____

Waist measurement at the navel _______inches (Do not measure at your
      "true" waist which is usually 1-2 inches above the navel.)
      Women only:  Hip measurement at the widest point________inches
      Men only:  Wrist measurement________inches

Pregnant or lactating?     Yes     No    (circle one) 

Doctor____________________________________________


Current Health Concerns:




Current Diagnosis(es):




Current Medications(s)/Prescribed Treatments:




Past Diagnosis(es)/Illness(es):




Family history of cardiovascular disease and adult onset diabetes:




Check, circle, and/or fill in whichever apply to you:

    My current salt use is:  low____, moderate____, heavy____, by taste____.

    I have never used much or any salt ...   True   or   False

    I previously used salt more than now ...  True   or   False

    I crave salt and/or salty foods ...   True   or   False

    I have followed a low salt diet for _____ years.

    Number of glasses of water each day: _____

    Average energy level on a scale of 1 to 10: _____

    Average stress level on a scale of 1 to 10: _____

Milk intolerance:          Yes   No
    If "yes", list symptoms: ____________________________________

Number of TOTAL pounds lost throughout your life dieting: _____

Do you take a calcium supplement(s)?  Yes   No

    If "yes", how much calcium daily? __________________

    What kind(s) of calcium? _____________________________

    How long?____________________

What other supplements do you take?____________________________

Do you have any silver (amalgam) fillings?    Yes   No

Root Canals?    Yes   No

Please indicate the NUMBER OF SERVINGS PER WEEK you have of each
of the following foods:

beef____  poultry____  lamb____   fish____  pork____  tofu____  soy milk____

milk____  cheese_____  yogurt____ cottage cheese____  eggs____  butter____

fresh fruit____  fresh vegetables____  breads, cereals, grains, pasta____

nuts and nut butters_____  sweets (cookies, cakes, candy, ice cream, etc.)____

caffeinated beverages____  wine_____  beer_____  liquor_____  

Please specify kind(s) and the number of weekly servings of:

   oils___________________________________________________________

   protein powder __________________________________________________

EXERCISE
Please describe the type, frequency and duration of physical exercise.

_______________________________________________________________

_______________________________________________________________ 

INDICATOR CHECK LIST - circle Y or N:
    symptoms caused by food(s)  Y  N                    
    cold hands and/or feet  Y  N 
    grogginess upon waking  Y  N
    low or absent sweating  Y  N
    dizziness after standing quickly  Y  N
    bruise easily  Y  N
    brittle/peeling fingernails  Y  N
    muscle tightness/inflexibility  Y  N
    joint stiffness/aching/swelling  Y  N
    poor concentration/memory  Y  N
    hard, dry thin, strained stools  Y  N 
    loose, frequent, watery stools  Y  N
    difficulty relaxing  Y  N
    frequent urination  Y  N
    gas  Y  N
    mood swings  Y  N
    ringing in the ears  Y  N
    eczema  Y  N
    fluid retention  Y  N
    dry skin  Y  N
    brittle/dull/dry hair  Y  N
    headaches  Y  N
    sleep disturbances  Y  N
    cold intolerance  Y  N
    symptoms caused from delays in eating  Y  N
    symptoms caused from fumes, chemicals, odors  Y  N
    cravings for sweets and/or carbohydrates  Y  N

WOMEN ONLY 
    menstrual cramping  Y  N
    PMS  Y  N
    menopause  Y  N
    number of childbirths     ____

MEN ONLY
    difficulty with urination   Y  N

     (end of form)