Health Intake Form

Dr. Cabral

Health Intake Form

The health questionnaire below is a standard wellness client intake form used in Functional Medicine to get a more complete health history. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying root causes of illness and will also assist us to formulate your wellness recommendations.

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About You

Let’s start with a few details to help us understand who you are.

Your Name(Required)

First Last

Your Address

Street Address Address Line 2 City ZIP Code

How Can We Reach You?

Share the best ways to reach you so our team can follow up and support your wellness journey.

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone:(Required)

Time Zone:(Required)

Best Time to Call You:(Required)

Personal Background

These questions help us better understand your personal profile as it relates to health.

Age:(Required)

Please enter a number from 3 to 120.

Place of Birth:(Required)

Height (feet):

Please enter a number from 1 to 9.

Height (inches):(Required)

Please enter a number from 0 to 11.

Weight:(Required)

Please enter a number from 1 to 600.

Gender:(Required)

Occupation:(Required)

Current Concerns

Tell us what you’re experiencing so we can get a clear picture of your primary concerns.

Referred By:(Required)

(If working with an IHP coach, please list name) *

Describe Problem(s):(Required)

What treatments have you tried?(Required)

Has anything been successful?(Required)

Home & Life Circumstances

These questions help us understand your daily environment and the factors that may impact your well-being.

With whom do you live?(Required)

(Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister

Do you have any pets or farm animals?(Required)

Have you or your family recently experienced any major life changes?

If Yes, Please explain:

Have you experienced any major losses in life?(Required)

If Yes, Please explain:

Previous employment:(Required)

How much time have you lost from work or school in the past year?

Did you feel safe growing up?

Trauma & Safety Background

These questions help us understand your personal history and any experiences that may influence your overall well-being.

Do you feel safe, respected and valued in your current relationship?(Required)

Have you been involved in abusive relationships in your life?(Required)

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?(Required)

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?(Required)

Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues?(Required)

Allergies & Medical History

These questions help us understand your diagnoses, treatments, and medical background.

Please list any allergies or intolerances:

(food or environmental)

List past Medical and Surgical History

List previous hospitalizations:

How often have you taken antibiotics?(Required)

(as a child and adult)

How often have you have taken oral steroids?(Required)

(e.g., Cortisone, Prednisone, etc.)

What medications are you taking now?

(including birth control/hormones)

List all vitamins, minerals, and other nutritional supplements that you are taking now.

Were you a full term baby? A preemie? Breast-fed or Bottle-fed?(Required)

Diet, Eating Patterns & Digestive Health

These questions help us understand your eating habits, food reactions, and digestive health.

As a child did you eat a lot of sugar and/or candy?(Required)

What is your typical daily diet:(Required)

(List typical meals and snacks)

How many servings of the following do you consume each week?(Required)

(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert.)

Are you on a special diet?(Required)

Is there anything special about your diet that we should know?(Required)

Please Explain (Special Diet)

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?(Required)

If yes, are these symptoms associated with any particular food or supplement(s)?

Do you feel worse when you eat certain foods?(Required)

Example: fat, protein, carbs, etc.

Which foods make you feel worse?

Do you feel better when you eat certain foods?(Required)

Example: fat, protein, carbs, etc.

Which foods make you feel better?

Does skipping a meal greatly affect your symptoms?(Required)

Have you ever had a food that you craved or really “binged” on over a period of time?(Required)

Do you have an aversion to certain foods?(Required)

Please Explain (which foods):

How many bowel movements (BM) do you have per day?(Required)

Please enter a number from 0 to 100.

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)?(Required)

Do you have intestinal gas?(Required)

If so, when (gas):

Lifestyle, Substances & Environmental Exposure

These questions help us understand how daily habits, substances, and environmental factors may impact your wellness.

How many times per week do you drink alcohol?(Required)

Please enter a number from 0 to 100.

Have you ever used recreational drugs?(Required)

Have you ever used tobacco?(Required)

For how long? (tobacco)

Are you exposed to secondhand smoke regularly?(Required)

Do you have mercury amalgam fillings in your teeth?(Required)

How many mercury fillings?

Do you have any artificial joints or implants?(Required)

Which joints or implants do you have?

Do you feel worse at certain times of the year? *(Required)

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *(Required)

Do odors affect you? If so, which ones?(Required)

How would you rate your current level of stress? *(Required)

Please enter a number from 1 to 10.

0-10

Cycle, Mental Well-Being & General Wellness

These questions help us understand your emotional health, cycle patterns, sleep, exercise, and overall lifestyle balance.

If you have a cycle, how long is it and is it regular?(Required)

Do you have any problematic symptoms related to your cycle?(Required)

If you have a cycle, how long is it and is it regular?(Required)

Any other comments related to your cycle?

(flow, clots, mood changes, etc.)

Have you ever had psychotherapy or counseling?(Required)

List your hobbies and leisure activities:(Required)

Do you exercise regularly?(Required)

How many times per week?(Required)

What type of exercise is it?(Required)

Do you struggle with insomnia or interrupted sleep?(Required)

Do your parents or siblings have (or had) any health issues?(Required)

Please explain:

Please add any other information you feel is important:

Why do you believe you would be a good candidate to work with Stephen Cabral? *

Congratulations

You are on the path to taking your first step towards health and wellness!

Consent(Required)

I have read and understand everything on this page. I acknowledge Stephen Cabral and his associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Stephen Cabral, his lab partners, his independent representatives, associates and affiliates 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 their natural health services.(Required)

Dr. Cabral