Patients Get Started
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This takes about 15 to 20 minutes. Please have your list of medications and supplements handy.

Required

Patient Information
Gender
Marital statusCheck "Child" if this paperwork is for a child. Extra questions for parents will appear.
Example: 5 ft 6 in
Pounds
Contact Information
Reason for Your Visit
Type of visit you are requesting
Include name, how long, and what for. Include birth control, aspirin, and pain meds.
Include surgeries, operations, plastic surgery, and trauma. Please give dates.
Include food, environmental, chemical, and drug allergies.
Name and why you are taking them.
Anything else that may be important.
Lifestyle
Do you smoke?
Do you use any recreational drugs?
If yes, select
How is your sleep?
Digestion and Elimination
Digestion
Urination
Consistency
Color
Amount
Other
Exercise and Environment
Do you exercise?
How many hours daily do you spend...Hours per day. Leave blank if none.
Diet
What kind of water do you drink?
Beverages you drinkHow many times per day (D) or per week (W). Example: 2 D. Leave blank if never.
Foods you eatHow many times per day (D) or per week (W). Example: 3 W. Leave blank if never.
Women's Health
Are you pregnant?
Are you breastfeeding?
Do you have monthly periods?
Are you going through menopause?
Flow
Select any that apply
Symptom Survey

Rate each symptom based on the last 30 days. 0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Heart
Symptom01234
Shortness of Breath
Skipped/Rapid Heartbeat
High/Low Blood Pressure
Chest Pain
Tightness in Chest

Total Heart: 0

Mouth, Throat
Symptom01234
Dry Mouth
Canker Sores
Cold Sores
Tooth Pain
Bleeding Gums
Gagging/Clearing Throat

Total Mouth, Throat: 0

Skin, Hair, Nails
Symptom01234
Flushing
Cold Hands/Feet
Acne
Dry Skin/Oily Skin
Hives/Rashes
Eczema, Psoriasis
Hair Loss
Cracked Heels on Feet
Bruising
Brittle Nails

Total Skin, Hair, Nails: 0

Sleep
Symptom01234
Can't Fall Asleep
Wake Up Often
Nighttime Urination
Wake Up Tired
Bad Dreams/Nightmares
Night Sweats

Total Sleep: 0

Lungs
Symptom01234
Difficulty Breathing
Chest Congestion
Coughing
Asthma

Total Lungs: 0

Digestive
Symptom01234
Nausea
Diarrhea or Vomiting
Heartburn/Reflux
Straining on Bowel Movement
Day without Bowel Movement
Gas, Belch, Bloating
Hemorrhoids

Total Digestive: 0

Allergies
Symptom01234
Watery, Itchy Eyes
Runny Nose
Sneezing
Itchy Throat
Itchy Skin
Post Nasal Drip

Total Allergies: 0

Head, Eyes
Symptom01234
Blurred Vision
Pressure
Faintness
Dizziness
Headaches

Total Head, Eyes: 0

Joints, Muscles, Bones
Symptom01234
Twitching
Cramping
Stiff & Achy Joints
Pain in Joints
Swelling in Joints
Muscle Aches
Muscle Pains
Osteoporosis
Numbness/Burning
Flat Feet/Fallen Arches

Total Joints, Muscles, Bones: 0

Ears, Sinus, Nose
Symptom01234
Popping Ears
Fluid in Ears
Ringing in Ears
Hearing Loss
Ear Infections
Excessive Mucous
Stuffy Nose
Sinus Headache
Nose Bleeds

Total Ears, Sinus, Nose: 0

Immune
Symptom01234
Frequent Illness
Sore Throat
Fever
Genital Itch/Discharge
Yellow Nail Fungus

Total Immune: 0

Urinary Tract
Symptom01234
Frequent Urination
Burning on Urination
Dribbling Urine
Leaky Bladder
Blood in Urine
Kidney Stones

Total Urinary Tract: 0

Energy
Symptom01234
Fatigue/Tired
Sluggishness
Hyperactivity
Restlessness
Brain Fog
Irritable if Miss Meals
Swelling Hands & Feet

Total Energy: 0

Emotions
Symptom01234
Mood Swings
Anxiety/Fear/Nervous
Anger/Irritability
Panic Attacks
Depression
Sense of Despair

Total Emotions: 0

Hormones
Symptom01234
Oily Skin, Acne
Pain during Period
Breast Tenderness
Irregular Cycle
Weight Gain
Cry Easily
Vaginal Dryness
Hot Flashes
Loss of Sex Drive
Erectile Dysfunction
Balding
Anger Easily

Total Hormones: 0

Total for all sections: 0

Life Experiences

These questions are about your first 18 years of life. Your answers are private and help us understand your health. You may skip any question.

Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or try to or actually have oral, anal, or vaginal sex with you?
Did you often feel that no one in your family loved you or thought you were important or special? Or your family didn't look out for each other, feel close to each other, or support each other?
Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Were your parents ever separated or divorced?
Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Was a household member depressed or mentally ill or did a household member attempt suicide?
Did a household member go to prison?
Child Information

For a parent or guardian filling out this form for a child.

Check all that your infant or toddler is having trouble with
Pregnancy and Birth History

About the pregnancy and birth of this child.

Who delivered your baby?
How was your baby delivered?
Did you receive any medications during labor?
Mother's Health History
Do you take vitamins?
Do you smoke?
Do you drink alcohol?
Do you drink soft drinks?
Do you drink coffee?
Do you consume dairy products?
Consent to Treat

I voluntarily consent to evaluation and care by the doctors and staff of Living Well Clinical Nutrition Center. This may include clinical nutrition, chiropractic care, and other services offered by this office.

I understand that the services provided here are nutritional and wellness in nature. They are not a substitute for diagnosis or treatment by my medical doctor. I will continue to see my medical doctor as needed.

I understand that no promise or guarantee has been made about the results of my care. I may ask questions about any recommendation at any time, and I may stop care at any time.

I certify that the information I have provided is true and complete to the best of my knowledge. I will tell the office about any changes to my health or medications.

If I am signing for a minor or another person, I confirm that I am their parent, legal guardian, or legal representative and have the authority to consent for them.

Signature
Sign with your finger or mouse.

Date: November 2, 2026

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