Lifestyle Assessment/Intake Form
PART 1
Name: ________________________________ Date of Birth:___________________
Date: ________________ Age:_________________ Sex:______________________
Occupation: _________________________________________________________
What is your purpose for this visit?
__________________________________________________________________
What are your main health concerns/complaints?
__________________________________________________________________
__________________________________________________________________
Do you have any ailments related to your main health concerns?
__________________________________________________________________
What are you current stress levels on a scale of 1 – 10? ____________________________
How does your stress manifest and what are your coping mechanisms?
__________________________________________________________________
Are you currently taking any medications or supplements? If so please list.
Medication/Supplement Dosage
Since
Reason
What are your favorite foods?
_________________________________________________________________
What foods do you crave, if any?
____________________________________________________________
How much water do you consume daily?
____________________________________________________________
Myia Sparreboom RHN/ Spruce Wellness/ www.sprucewellness.ca/ 250-464-4234
Do you experience any symptoms if meals are missed? Explain.
__________________________________________________________________
Do you experience any symptoms after eating? Explain.
__________________________________________________________________
On a typical day, what do you eat, and at what time:
Breakfast:___________________________________________________________
Lunch:_____________________________________________________________
Dinner:____________________________________________________________
Snacks:____________________________________________________________
__________________________________________________________________
Beverages:__________________________________________________________
Are you currently using any other therapies? (naturopathy, exercise, massage, yoga, etc.)
Explain.____________________________________________________________
__________________________________________________________________
________________________________________________
Do you have a support system? (family, friends, church/spiritual practice, etc)
__________________________________________________________________
__________________________________________________________________
PART 2
How were you referred?
______________________________________________________________
What problem brings you or your child to this appointment? __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What did the symptoms begin?
________________________________________________________
Are your symptoms getting worse? Circle:
Yes or No.
Do you have any of the following symptoms? Please check all that apply.
 Cough
 Wheezing
 Shortness of
 Runny Nose
 Nasal Congestion
 Itchy Nose
 Nasal Polyps
 Poor Sense of Smell
 Ear Infections
 Eczema
 Hives/Swelling
 Headaches
Breath
 Chest tightness
 Sneezing
 Phlegm / Sputum:
 Itchy / Watery Eyes
 Postnasal Drip
 Sinus Infections
 Blocked Ears
 Snoring
 Fatigue
 Other
Color______________
Which of the following trigger (or cause) the symptoms. Please check all that apply.
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Grass
Hay
Mold & Mildew
Basements
Leaves
Cats
Latex (rubber)
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Dogs
Horses
Other animals
Alcoholic Beverages
Cosmetics
Aerosol sprays
Other:
__________________________
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Perfumes
Insecticides
Odors
Drafts
House dust
Smoke
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Pollution
Exercise
Nervousness
Cold Air
Humidity
Weather Changes
When are your symptoms worse?
 Year Round
 January
 May
 September
 February
 June
 October
 March
 July
 November
Yes or No.
 April
 August
 December
Are symptoms better away from home?
Circle:
If yes, when? _________________
Occupation (current or previous):
___________________________________________________
Any harmful exposure at work or school?
___________________________________________________
Environmental Survey
How long have you lived in your house/apartment?
___________________________________
Approximately how old is your house/apartment/condo?
___________________________________
Do you live in a:
 House
 Apt / Duplex
 Condo / Town House
Do you live
 In the city
 In the suburbs
 Rural areas
Do you have a basement?
 Yes
 No
Is your house built on a slab?
 Yes
 No
Type of heating system?
 Hot Air
Do you use a:
 Humidifier
# Of Pets?
Indoor or Outdoor?
 Steam (radiator)
 Electric
 Wood/Coal Stove
 None
 Cats
 Hot water baseboard
 Dehumidifier
 Dogs
Are there any tobacco smokers in your house?
 Yes
 No
Is your bedroom in the basement?
 Yes
 No
 Air Cleaner
 Birds
 Other
 Yes
Do you have allergy proof encasing for pillow or mattress
 No
What type of pillow do you have?
__________________________________________________
What type of comforter do you have?
__________________________________________________
What type of floor covering do
 Wall to wall
you have in your bedroom?
 Area rug
 Animal skin
 Bare floor
How old is your mattress? ______ What is in your mattress? (I.e. cotton, horsehair, etc.) ___________
 Yes
Do you have air conditioning?
 No
If yes,
 Window Unit
Do you have problems with roaches or mice?
 Yes
 No
Do you have water leaks, mold contamination?
 Yes
 No
Is your home/apartment excessively humid?
 Yes
 No
 Central
Your Past Medical History
Check all that apply:
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Diabetes
Cancer
High blood pressure
Anemia/Blood
Disorder
 Asthma
 Back problems
 PMS
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Liver disease/hepatitis
Heart problems/murmur
Osteoporosis
Kidney/bladder
Disease
 Glaucoma
 Emphysema
 Endometriosis
If yes to any of the above, please explain:
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Peptic
Thyroid disease
Arthritis
Hay fever
 Diarrhea
 Cataracts
 Infertility
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Heartburn/reflux
Seizures
Migraines
Depression
 Anxiety
 Loss of hearing
 Menopause
____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you had your tonsils or adenoids removed?
 Yes
 No
Have you had ear, nose or sinus surgery?
 Yes
 No
If yes, please explain:
___________________________________________________________
___________________________________________________________
Do you smoke now?
 Yes
 No
How Much? _________________
# Of years? _____
Have you smoked before?
 Yes
 No
When did you stop? ___________
# Of years? _____
Family History
Who in your family has had?
Asthma ________________________________________________________________________________
Eczema ________________________________________________________________________________
Seasonal or Year Round Allergies
___________________________________________________________
Other Allergies (drugs/bees/food etc) ________________________________________________________
Sinus Problems
_________________________________________________________________________
Please list any hospitalizations regardless of cause:
_____________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
List any food allergies and reactions experienced:
_____________________________________________
________________________________________________________________________________________
List any drug allergies and reactions experienced (i.e. penicillin, aspirin, sulfa, latex, etc): ______________
________________________________________________________________________________________
Describe any reaction to insect stings:
____________________________________________________
Food Stressors Section:
Check any symptoms that you have experienced:
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Abdominal cramping
Anaphylactic shock
Arthritic type symptoms
Canker sores
Celiac’s disease
Constipation
Depression
Diarrhea or loose stools
Difficulty concentrating
Emotional upset
Eczema
Fatigue or sudden drops of energy after meals
Gas or bloating
Heartburn or indigestion
Hives
Irritable bowel syndrome (IBS)
Irritability
Itching – skin or rectal
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Migraine headaches
Nausea
Nocturnal enuresis
Red rash around mouth, reddening or swelling of skin
Rhinitis
Runny nose
Stiffness of joints
Stomach ache
Swelling of lips and face
Swelling of the joints
Vomiting
Wheezing
Miscellaneous: Indicate any additional information about your symptoms:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Client Statement
I understand and acknowledge that the services hereby provided are at all times restricted
to consultation on the subject of health matters intended for general well-being and are
not meant for the purposes of medical diagnoses, treatment or prescribing of medicine
for any disease, or any licensed or controlled act which may constitute the practice of
medicine. This statement is being signed voluntarily. All information will be kept strictly
confidential.
Name (print):________________________________________________________
Address:____________________________________________________________
__________________________________________________________________
Phone:__________________________ Email:______________________________
Signature:___________________________________ Date:____________________
Thank you. I look forward to working with you.
Myia Sparreboom RHN/ Spruce Wellness/ www.sprucewellness.ca/ 250-464-4234