Assessment Intake Form Step 1 of 3 33% Personal InformationName Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneAlternate PhoneEmail Occupation Date of Birth Month Day Year Gender Male Female Height Weight Waist Circumference Concerns & GoalsWhat is your main wellness concern or overall goal?Medical HistoryMedical ConditionsPlease mark all that apply Heart Disease Osteoporosis Diabetes COPD/Emphysema High Cholesterol Asthma or Bronchitis Hypertension / High Blood Pressure Food Allergies or Intolerances Celiac Disease Gastrointestinal Disorders or Issues Chewing or Swallowing Issues Cancer Migraine Headaches Kidney Disease Anxiety Disorder Gout Sleep Disorder Arthritis Depression Fibromyalgia Pregnant Recent Surgeries Other (Specify) Other Medical Condition Lab ResultsDate of Last Lab Results Month Day Year Blood Pressure Total Cholesterol LDL HDL Triglycerides Glucose A1C Additional Lab Results Not in Normal RangeFamily HistoryFirst Degree RelativesPlease check if any of your first degree relatives (parents, sibling, child) have experienced any of the following conditions. Cancer High Blood Pressure High Blood Cholesterol Heart Disease Obesity Diabetes Other (Specify) Other Medical Condition (Relatives) Current Medications & SupplementsCurrent MedicationsPlease list any medications you are currently taking, as well as any medications that your doctor has prescribed that you may not be taking.Current Supplements & OTC MedicinesPlease list any supplements or over the counter medicines you are currently taking, including herbs, vitamins and minerals. Current StressWhat is your current stress level? None Mild Moderate Severe If you are stressed, in what way do you think it could be affecting your health?What are you currently doing or have tried to do in the past to reduce your stress?What barriers keep you from reducing your stress?How important is it for you to reduce your stress?Current NutritionHow many meals and snacks do you eat per day and what type of foods do you consume?At your current calorie intake are you reducing weight, gaining weight, or maintaining weight?If you were to improve your nutrition, what do you feel you need to do differently?What barriers get in the way of your healthy eating?How important is it for you to change your eating habits?Current ExerciseDo you exercise on a regular basis? If so, how many days a week, how many minutes, and what type of exercise are you doing?Do you get regular movement throughout the day, or are you more sedentary?If you were to improve your exercise routine, what do you feel you need to do differently?What barriers get in the way of your exercising?How important is it for you to add more movement to your life?Current SleepHow many hours of sleep do you get on average per night?If you aren't sleeping, how do you think it is affecting your life?Is it hard to go to sleep, or do you wake in the night and can't go back to sleep, or both?What are you currently doing to improve sleep?What barriers get in the way of increasing your hours of sleep?How important is it for you to get more sleep? Consent, HIPAA Acknowledgement, Email Permission FormI give consent for iBalance Wellness LLC to provide information and guidance to myself or the client for which I am legally responsible. The information and guidance received are in regard to health factors within my own control: diet, nutrition, behaviors affecting my lifestyle. I understand that Niesje Buaas RDN, LD of iBalance Wellness LLC is a Registered Dietitian/Nutritionist and does not dispense medical advice or prescribe treatment for any medical condition. The services provided nutrition, exercise, and/or stress education and support are to enhance my goals for my wellness. I understand these services are not a substitute for medical care by a medical provider. I also understand that any evaluation or testing provided through iBalance Wellness LLC is not intended to diagnose disease, but use as a guide to help me achieve my wellness goals. I agree to hold iBalance Wellness LLC (Niesje Buaas RDN, LD) harmless for claims or damage in connection with our work together. This is a contract and a release of potential liability between myself and iBalance Wellness LLC (Niesje Buaas RDN, LD). Documentation (medical records, personal information, and session notes) will be stored in a secure location and strictly confidential, unless I consent to sharing my medical and/or wellness information by way of a signed release.Client Signature*Please read our HIPAA Notice of privacy practices which has been attached to your confirmation email. This can also be found at https://www.ibalancewellness.com/privacy. You do not need to print unless you would like a copy for you own reference. Please sign and acknowledge the following: I have received iBalance Wellness LLC HIPAA Notice of Privacy. Today's Date* MM slash DD slash YYYY Email Permission*Email is inherently insecure; please check one of the boxes below to give us permission or not to send emails regarding wellness plans, appointments, and follow-ups to questions and/or other communications. Yes, I understand the security limitations of email and agree to using email as a form of communication. No, I prefer that you do not contact me by email. PhoneThis field is for validation purposes and should be left unchanged. Δ Ready to live your best life? Let's get started!
