Client Intake Form

Hidden

Date*

Section 1: Personal Information

Patient Name*

Date of Birth*

Alberta Health Care No.*

Weight*

Height*

Allergies:

Attach an image of your Drug Insurance (optional)

Max. file size: 50 MB.

Phone*

Email*

Address*

Family Doctor

Last Family Doctor Visit

Other Health Care Providers

How Did You Hear About Us?

Do you currently use tobacco?*

Yes
No

How many packs do you smoke per day?

Do you Vape at this time?*

Yes
No

How motivated are you to quit in the next 30 days?*

Do you currently consume alcohol?*

Yes
No

If yes, do you have concerns with consuming alcohol?

Do you currently consume caffeinated products?*

Yes
No

How much caffeine do you consume per day?*

Do you currently use cannabis products?*

Yes
No

Is it for medical use or recreational?*

Medical
Recreational

Section 2: Chronic Medical Conditions

Please check off if you have any of the following medical conditions:

Other medical conditions:

If you have any addictions, what are they?

Current list of prescription medication (list below or upload list at the end of this section):

Current list of supplements or nutraceuticals:

How would you rate your current health?

Poor
Fair
Good
Excellent

Rate your stress:

Low
Average
High
Unbearable

Sources of stress:

Work
Family
Health
Money
Other*

If you have other sources of stress, what are they?

Exercise:*

Relationship status:

Single
Married
Common-Law
Divorced

Occupation

Hours of work per week

List 3 current health concerns (list in primary order)*

What have you previously tried to address your concerns?*

Upload any relevant info

i.e.: list of current prescription medication, lab work, food sensitivity, tests, etc.

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Section 3: Nutrition Consultation

Are you signing up for a nutrition/weight management program?*

Yes
No

Family History (check all that apply)

Type of Cancer

Family History - Other

Physical Status

Usual adult body weight

Highest weight

At age

Lowest weight

At age

Diet

Food allergies:

Food dislikes:

Do you get noticeably irritated, weak or lightheaded if you haven't eaten in a while?

Yes
No

Do you crave certain foods?

Sweets
Chocolate
Bread/Pasta
Fried Foods
Alcoholic Drinks
Sodas/Diet Sodas
Meat
Other*

Other foods craved:

How often do you have bowel movements?

Bowel movement frequency

How many times do you urinate?

Urination frequency

Dental health issues:

Prone to Cavaties
Gum Disease
Bleeding Gums

Are your nails week or brittle?

Yes
No

Hours of sleep per night:

To what extent will you commit to achieving better health?

Little
Moderate
Major
Extreme

Additional information

Section 4: Declaration of Consent

Declaration and Consent of Resident or Resident’s Substitute Decision Maker (as applicable)

Consent*

I give Sage Plus Clinical pharmacy the access to all my information via NETcare*

Signature*

Name*

Date of Consent*

Name

This field is for validation purposes and should be left unchanged.