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Client Intake Form
Client Intake Form
sageplus
2020-09-15T15:06:44+00:00
Date
*
Date Format: DD slash MM slash YYYY
Section 1: Personal Information
Patient Name
*
First Name
Last Name
Date of Birth
*
Date Format: DD slash MM slash YYYY
Alberta Health Care No.
*
Weight
*
Unit of measurement for weight
*
lbs
kg
Height
*
Unit of measurement for weight
*
Centimeters
Inches
Allergies:
Drug Insurance
Or attach an image of your Drug Insurance
Phone
*
Email
*
Address
*
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Family Doctor
Last Family Doctor Visit
Date Format: DD slash MM slash YYYY
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?
*
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
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:
Hypertension
Diabetes Mellitus
COPD
Asthma
Anxiety
Depression
Panic
ADD/ADHD
Eating Disorders
Paranoia
Autism
Hallucinations
Personality Disorder
Bipolar
Primary Insomnia
Post Traumatic Stress Disorder
Dementia
Obsessive Compulsive Disorder
Schizophrenia
Addictions
Other
If you have any addictions, what are they?
Current list of prescription medication:
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
Aka. lab work, food sensitivity, tests, etc.
Drop files here or
Section 3: Nutrition Consult Series - Personal Wellness Report
Are you interested in a nutrition/weight loss program?
*
Yes
No
Family History (check all that apply)
Stroke
High BP
Depression
Heart Disease
Arthritis (RA or OA)
Cancer
Diabetes
Weight Problems
Ulcer
Psoriases
Glaucoma
Type of Cancer
Usual adult body weight
Highest weight
Unit
kg
lbs
At age
Lowest weight
Unit
kg
lbs
At age
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?
How often
Per Day
Per Week
Per Month
How many times do you urinate per day?
How is your dental health?
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
Behaviours Past or Present
Count Calories
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Count Fat Grams
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Dieting
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Diet pills
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Binge Eating
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Fat Restriction
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Fluid Restriction
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Discomfort with your body size
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Other
Yes
No
Frequency
Most Recent
Date Format: DD slash MM slash YYYY
Additional information
3-Day Food and Activity Journal
Day 1
Date Format: MM slash DD slash YYYY
Breakfast
Snack
Lunch
Snack
Dinnner
Snack
Activity
Day 2
Date Format: MM slash DD slash YYYY
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Activity
Day 3
Date Format: MM slash DD slash YYYY
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Activity
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 vie NETcare
*
Signature
*
Name
*
Date of Consent
*
Date Format: DD slash MM slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
