IHP Health Intake Form Todays Date Month Day Year Name First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Birth Date Month Day Year Height Weight Sex (M/F) Current occupation (plus list any previous occupations, if different/relevant) Add RemoveDescribe your health issue(s); mention everything, no matter how small; include physical, emotional, mental, spiritual issues as relevantWhat treatments have you tried?Has anything been successful?With whom do you live?Do you have any pets or farm animals? If yes, where do they live?Have you lived or travelled outside of your country of residence (beyond short holidays or business trips)? If so, when and where?Have you or your family recently experienced any major life changes? If yes, please commentHave you experienced any major losses in life? If so, please commentHow much time have you lost from work in the past year? Why?List past medical and surgical history Add RemoveList previous hospitalisations Add RemoveHow often have you taken antibiotics?How often have you have taken oral steroids?What medications are you taking now? Add RemoveList all vitamins, minerals, and other nutritional supplements that you are taking now Add RemoveWere you a full-term or premature baby? Normal or C-section delivery? Breast-fed or Bottle-fed? What is your typical daily diet, e.g. ‘standard western’, ‘Mediterranean’, vegetarian/vegan, paleo, keto, etc:How much of the following do you consume per week on average?Black tea/Coffee (w/ Sugar?) Soda Energy Drinks Water Meat (red/white Dairy (Milk/cheese/yogurt) Eggs Bread/gluten Fruits vegetables Processed foods/snacks Sweets/chocolate Dessert Are you on a special diet, e.g. one recommended or prescribed by a doctor or nutritionist for a specific reason?Do you have symptoms immediately/soon after eating, such as belching, bloating, stomach pain, diarrhoea, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)?Does skipping a meal greatly affect your symptoms?Have you ever had a food that you craved or really "binged" on over a period of time?Do you have an aversion to certain foods? If yes, what foods?How many bowel movements (BM) do you have per day? Do you have any constipation (straining or less than 1 BM/day) or diarrhoea (loose stool)?Do you often have intestinal gas? If so, when?How many times per week do you drink alcohol? How much each time?Have you ever used recreational drugs?Have you ever used tobacco? (If so, for how long?)Are you exposed to second-hand smoke regularly?Do you have mercury amalgam fillings in your teeth? If so, how many?Do you have any artificial joints or implants? If so, which ones.Do you feel worse at certain times of the year?Have you, to your knowledge, been exposed to toxic metals in your job or at home?Do odours affect you? If so, which ones?How would you rate your current/recent level of stress? When in the day do you typically experience stress?How would you describe your sleep?Have you ever had psychotherapy or counselling? List your main hobbies and leisure activities Add RemoveDo you exercise regularly? If so, what type and how many times a week?Do your parents or siblings have (or had) any health issues? If so, please explain:If you are female, do you have any issues with your menstrual cycle?Congratulations, you have taking your first step on the path to health and wellness! Please read and sign the following disclaimerI have read and understand everything on this page. I acknowledge that Craig Danehy is a natural health practitioner, and that he does not diagnose, treat or cure any illness or disease. Further, the undersigned releases Craig Danehy from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of his natural health services. Client Signature Reset signature Signature locked. Reset to sign again Date Month Day Year All information provided by the client will be held in strict confidence, and will not be shared with anyone without the client’s express permission
