Client Intake Form Nikki Reed Wilson LLC 1 Nikki Reed Wilson LLC

Nikki Reed Wilson LLC Dr. Nikki Reed Wilson, BCND, CNHP, HLC 110 Travis Street Suite 133 Susan Leger Lafayette, LA 70503 Christie Pate www.NikkiReedWilson.com Office: 337.889.0615 Fax: 337.889.0601 email: [email protected] Nikki Reed Wilson, Board Certified Naturopathic Doctor and her staff will not prescribe for or treat any disease. All clients are encouraged to seek competent medical help when those services are deemed necessary. The client accepts total responsibility for his or her own health care and maintenance. Dr. Wilson’s intent is to provide educational information for the purpose of assisting you with the lifestyle changes and decisions necessary to regain and maintain an environment needed to produce a healthy mind, body and spirit. Wellness programs involve lifestyle changes, elimination of harmful routines and habits, and the cultivation of positive mental attitudes. Dr. Wilson is committed to the highest level of integrity in all her dealings with clients. Appropriate actions and safeguards to protect your personal information will be followed. DISCLAIMER • I understand that I am here to learn about natural health and better lifestyle practices and that I will be offered information about lifestyle changes, foods, supplements, herbs and emotional work as a guide to general health. • I understand that information about traditional uses of supplementation that may create a healthy balance in the body may be discussed, and that this is not intended to be interpreted as a substitute for a licensed physician’s treatment. • I understand that I should continue to see any medical doctors under whose care I am currently, and that any prescription medication should not be altered without first consulting the doctor who prescribed it. • I have read all of the above and understand and agree with it completely. I therefore consent to participation with Nikki Reed Wilson, BCND, HLC, CNHP and her staff in a program within the framework stated above. _____________________________________________ Printed Name _____________________________________________ Signature *Parent or legal guardian may sign for children. Client Intake Form Nikki Reed Wilson LLC 1 Name: _____________________________________________ Date: _____________ Address: _______________________________________City:___________________zip:___________ Email: _______________________________________________________________________________ Phone: _________________________ Cell Phone: ________________________ Do you text? Y or N Occupation: _______________________________________________________ Date of Birth: ________ Age: ________ Sex: _______ Weight: ___________ Blood Type: _________ Currently pregnant? ________ Breastfeeding? _________ Would like to be pregnant? ________ General Health Information List your current health concerns: ____________________________________________________ ________________________________________________________________________________ Describe your energy level 1-­‐10 with 10 being the highest:_______________________________ Describe your stress level 1-­‐10 with 10 being the highest: _______________________________ List your three top sources of stress: _________________________________________________ _______________________________________________________________________________ How many hours of sleep do you get each night? _______________________________________ Do you wake often in the night? If so, what time? _______________________________________ What time of day is the most challenging? _____________________________________________ How often do your bowels eliminate? ________________________________________________ How much water do you drink each day? _____________________________________________ Have you ever used herbs, homeopathics or flower remedies? ________________________ List current medications (prescriptions or over the counter): ______________________________ ________________________________________________________________________________ List current supplements: ___________________________________________________________ ________________________________________________________________________________ Where do you purchase your natural supplements? _____________________________________ Client Intake Form Nikki Reed Wilson LLC 2 Diet & Nutrition Are you open to dietary changes? ___________________________________________________ Do you feel that you get adequate nutrition from your daily diet? __________________________ Any known food sensitivities or intolerances? __________________________________________ Emotional & Spiritual Are you currently in a relationship? ___________________________________________________ Is there open communication? _______________________________________________________ Do you have a spiritual community or practice that you attend? If so how often?_______________ _________________________________________________________________________________ Exercise How do you feel about exercise in general? _____________________________________________ How often do you exercise? What type? ________________________________________________ If inactive, what reason keeps you from daily exercising? ___________________________________ __________________________________________________________________________________ Are you open to physical exercise suggestions? ___________________________________________ Client Intake Form Nikki Reed Wilson LLC 3