Health Consultation Intake — Cellular Vitality & Detoxification
Health Consultation Intake

Cellular Vitality & Detoxification
Health Consultation

Please complete this form as fully as possible. All information is held in the highest confidence.
Your honest answers allow us to meet you exactly where you are and support your body's innate wisdom to heal.

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Personal Information

Section 1
Weight History
Contact & Address
Personal & Household
Emergency Contact
How did you hear about us?
Why would you like to coach with us?
What is your major complaint? Please describe when each symptom began and be as specific as possible.
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Vitality Self-Ratings

Section 2

On a scale of 0–100 (0 = absolutely horrific, 100 = AMAZING), rate the following areas of your life.

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Medical History

Section 3
Current & Past Health Conditions
Anything else in your medical history you consider relevant? (Even from childhood)
Current Medications (include condition, dosage, and frequency)
MedicationConditionDosageTimes per Day
Current Supplements (include condition, dosage, and frequency)
SupplementCondition / PurposeDosageTimes per Day
Past Surgeries (include condition and dates)
Allergies (medications, food, seasonal, environmental)
Recreational Drug Use (current or past)
Family Health History
Does anyone in your family have similar symptoms to yours?
Have family members been diagnosed with fibromyalgia, chronic fatigue, or multiple chemical sensitivities?
Do you or any immediate family member have a history of cancer?
Any history of heart disease or myocardial infarction (heart attack)?
Any history of kidney dysfunction?
Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?
Have you ever been diagnosed with bipolar disorder, schizophrenia, or depression?
Have you ever been in an auto accident or received a major physical injury?
Have you ever had a blood transfusion?
Have you ever had a stroke?
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Employment, Hobbies & Housing History

Section 4
Employment History (include dates)
Past or present hobbies that could be sources of toxicity or chemical exposure
How often are you currently involved in these hobbies?
Housing History (type of homes, locations, dates)
Health Equipment Owned
Dental History
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Diet & Nutrition

Section 5
Dietary Yes / No Questions
Do you currently use tobacco products?
Have you previously used tobacco products?
Have you had your gallbladder removed?
Do you have difficulty digesting fats (avocado, coconut oil, olive oil, cheese)?
Do you consume dairy?
Do you have trouble with dairy?
Do you eat pork?
Do you eat gluten or wheat?
Do you have any trouble with gluten or wheat?
Did or do you drink diet soda?
Do you crave sugar or sweets?
Do you crave starches, grains, breads, or carbs?
Do you crave salty foods?
Do you need caffeine to get going?
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Sleep

Section 6
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General Health & Toxic Exposure

Section 7
Do you have a working carbon monoxide detector?
Have you ever had your home tested for radon?
Do you have high blood pressure?
Do you have low blood pressure?
Do you have sweaty or clammy hands?
Do you have swollen or tender lymph glands, tissue, or skin areas?
Do you have a Smart Meter on your home?
Have you ever had mono or suspected having mono?
Do you have bad breath unrelieved by brushing?
Do you have body odor unrelieved by washing?
Have you had unexplained weight loss of more than 10 lbs in 6 months?
Have you had weight gain of more than 10 lbs in the last 6 months?
Have you lived near or on a golf course, freeway, or tension wires?
Have you had any chemical exposures (cleaning spills, beauty salon, etc.)?
Do you have your house sprayed with pesticides for pest control?
Do you spray herbicide (weed killers) in or around your home?
Do you bug bomb your home?
Do you use conventional insect repellants on yourself or family?
Do you use perfume or cologne?
Do you use aerosol hairspray?
Do you get your nails done?
Do you use air fresheners in your home, work, or car?
Does your spouse or other family members work around chemicals?
Do you handle receipt paper often (e.g. as a cashier)?
Does your skin have a yellowish color (especially hands)?
Can you think of any other toxic exposures you may have had?
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Mental & Emotional Health

Section 8
Are you currently having any thoughts of suicide?
Do you have rapid mood swings?
Are you impatient, moody, or nervous?
Are you in a constant state of anxiety or fear?
Do you excessively worry?
Do you have difficulty making decisions?
Do you have an inability to relax or restlessness?
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Microbiome & Digestive Health

Section 9
Do you often have gas with a sulfur or foul smell?
Do you get heartburn or acid reflux?
Are you sensitive to supplements?
Have you ever been vegan or vegetarian for any length of time?
Can you tolerate meat?
Do you have a history of using antacids, proton pump inhibitors, or acid-blocking medications?
Do you currently or have you used birth control?
Do you currently or have you used hormone replacement therapy?
When you drink alcohol, do you get brain fog or feel toxic even after 1 serving?
Have you been on antibiotics in the last year?
Does your gut temporarily feel better after a round of antibiotics?
Do you have a history of antibiotic use as a child or adult?
Were you delivered by C-section?
Were you breastfed?
Do you drink filtered water?
Do you have a whole-house water filtration system?
Do you have a history of cold sores, warts, or skin tags?
Have you had food poisoning?
Do you have skin issues?
Do you have a history of athlete's foot or toenail fungus?
Do you have a history of jock itch or vaginal yeast infections?
Bowel Health
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For Females Only

Section 10A
Are you in or did you go through perimenopause or menopause?
Do you get hot flashes or night sweats?
Do you have a history of missed periods?
Do you have irregular periods?
Do you have pelvic or vaginal soreness or pain?
Do you have menstrual pain?
Do you have heavy menstrual bleeding?
Do you have infertility issues?
Do you have an underactive sex drive?
Do you have an overactive sex drive?
Do you have monthly weight gain?
Do you get bloating and swelling?
Do you have tender breasts?
Do you have vaginal itching?
Do you have vaginal discharge or sores?
Do you have vaginal dryness?
Have you ever had a sexually transmitted disease?
Do you have pain in your ovaries?
Do you get water retention?
Do you have a history of miscarriages?
Do you have a history of ovarian cysts?
Do you have a history of uterine cysts or fibroids?
Do you have a history of endometriosis?
Have you had a hysterectomy?
Have you ever taken estrogen, progesterone, testosterone, DHEA, or hGH?
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For Males Only

Section 10B
Do you have difficulty maintaining or attaining an erection?
Does ejaculation cause pain?
Is your sexual drive underactive?
Is your sexual drive overactive?
Do you have issues with premature ejaculation?
Do you have pain or coldness in genital area?
Do you have infertility issues?
Do you have a lack of early morning erections?
Do you have swollen genitals?
Do you have swelling in the groin?
Do you have genital sores?
Do you have a lump or mass in scrotum?
Do you have jock itch?
Have you ever had a sexually transmitted disease?
Do you use any prescriptions for improving sexual function?
Have you ever used HCG, DHEA, or hGH?
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Inner Terrain & Sacred Devotion

Section 11

Thank You ✦

Your intake has been received. Your coach will review everything before your session
so you can spend your time together going deeper, not filling in blanks.

We honor your courage in showing up for your healing.