Welcome to Our Intake and Forms Page!
Below you will find a long list of intake forms and questionnaires of various types.
These first three are for our initial appointment:
1) Health Alkemy Intake Form Online – this one asks for medical history, health wishes, diet and food frequency, and helps us see you from the inside out.
2) Electronic_Systems_Survey_Form – This survey helps me determine the nutritional deficiencies in your body. The information used in this survey was originally compiled by Doctors and experts in the field of nutrition in the 1950’s. This survey is now being used by tens of thousands of practitioners – all helping their patients to achieve maximum health through whole food nutrition.
The information gathered from this survey gives me “x-ray vision” into the nutritional status of your body. This enables me to do two things: first, to pinpoint which of your body systems are working below normal (i.e. the cardiovascular system) and second, to create a whole food supplement program designed to bring those systems back to normal.
3) MetabolicTypingTest – this is designed to help us determine your type of meal – amounts and types of proteins, fats, and carbohydrates. What we call your “fuel you put in your tank.” Some need high protein and fat = high octane fuel, and others need bit of everything = regular fuel, and lower fat/protein with healthy carbohydrate amounts.
Below are forms anyone can fill out and our office might ask for these at some point. But DO NOT FILL OUT IF YOU ARE A NEW CLIENT – USE THE FORMS ABOVE
Click on the highlighted area to get access to the form/s.
The Explorations one provides a brief window as to how a program might look visit by visit.
Explorations Introduction – this document helps the client see how to use our office and long-term goals/health
06-Toxicity Questionnaire –
Sleep Questionnaire – Electronic (1) –
Female History Questionnaire –
Male History Questionnaire –
Breast Cancer Risk Assessment2 –
05-Yeast Questionnaire –
EMF risk form (ElectroSmog in all its forms) –