Health Intake
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Email *
Name *
What steps do you take to manage stress (if/when)? :
Do you regularly exercise already?: *
What does a typical week of training/exercise look like?  (please be as detailed as able)
Preferred name to be addressed as:
How did you hear about Marshall: *
Complete Mailing Address:
Phone # (Primary) *
Cell or other?
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Phone # (secondary)
Cell or other?
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Age *
Gender
Height *
Weight *
Date of Birth
MM
/
DD
/
YYYY
Were you born via vaginal or cesarean delivery?
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Were you breastfed
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Where you grew-up, was there nearby industrial/conventional farming or animal feeding operations?:
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Did you have any health problems as a child? :
Did you receive antibiotics or other medications as a child?
Are your parents and grandparents still living?
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Did they or do they have any chronic health conditions?:
Do you have pets? How many and what kind(s)?:
In the past 7 days, I... (select the most accurately applicable corresponding frequency for each statement below)
Never
Rarely
Sometimes
Often
Always
Felt it hard to focus on anything other than my anxiety...
Felt sad...
Felt hopeless...
Felt part of a group of friends...
Experienced extreme exhaustion...
Felt anxious...
Was too tired to exercise strenuously...
Felt tense...
Had nothing to look forward to...
Felt grouchy...
Felt there are people I can talk to...
Felt angry...
Felt ready to explode...
Felt unhappy...
Ran out of energy...
My sleep was refreshing...
Had difficulty falling asleep...
Had difficulty staying asleep...
Got eight hours of sleep...
My fatigue limited me at work...
Felt depressed...
I couldn't go more than a few hours without eating...
Eating didn't satisfy my hunger...
Felt tired after eating...
Felt shaky in between meals...
Felt irritable in between meals...
Was too tired to think clearly...
Felt nervous...
Felt like a failure...
Felt uneasy...
Was irritated more than people knew...
Felt helpless...
Have been interested in sexual activity...
Have felt worthless...
Felt overwhelmed...
Felt Disconnected from myself...
Felt isolated / Disconnect from others...
Felt fearful...
Felt tired...
Felt stressed
Felt annoyed...
Enjoyed my job...
Made time for self-care and stress management...
Had cravings for fat...
Had cravings for sweets
Had cravings for meat...
Had cravings for carbohydrates...
Had cravings for salt...
Had diarrhea...
Went more than a day without defecation...
Had gas...
experienced stomach rumbling...
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Occupation:
How many hours per week do you currently work?:
Enjoy your work?:
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Describe your work situation, does it require sitting often, staring at a computer, being in-doors, away from windows, being around a high amount of wifi or other electrical devices, chemicals, using antibacterials often? Please explain:
Primary Sources of Stress?
Do you take any particular steps to improve stress management? :
Have supportive relationships in your pursuit of your health/performance goals?:
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Have areas in your life where you find passion, purpose, meaning?
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#1 health concern or performance goal (Please list them in order of importance to you): *
#2 health concern or performance goal:
#3 health concern or performance goal:
Do you have any other particular issues that you are concerned about, whether they seem important now or not?:
Have you recently worked with any other practitioners/trainers/coaches on these goals? If so, who?
Are you currently being treated for any medical conditions?:
Have you been diagnosed with any other conditions as an adult?:
Do you exercise regularly?:
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What are your current training/exercise goals (if different than top 3 health goals above):
What does a typical week of training/exercise look like? :
How much do you move outside of formal exercise? :
Shoes you usually exercise in?:
Shoes you usually work in?:
other shoes often worn?:
Any additional orthopedics, inserts, etc?:
Do you sleep well? :
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How long do you sleep for on average?
Do you take any particular steps to improve your sleep? :
Spend time outside? If so, how much time/ how often on average?
Time spent sitting per day?:
What medications and supplements do you currently take?:
What other medications and supplements have you regularly taken over the last year?:
Vaccination history in last 10 years (if any), which ones and when (approximately)?
List any/all sensitivities and/or allergies:
What does a typical day of food/drink look like? :
Do you take a particular approach to your diet (types of diets, foods you avoid, etc)? :
If so, why? :
Do you eat out often?:
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What percentage of your foods are organic, grown without chemicals, grass-fed or free-range?:
What percentage of your food is bought fresh/unprocessed (i.e. unprocessed produce, unprocessed meats)?:
Use alcoholic beverages?:
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If so, how often/what type & quantity?:
Do you use tobacco? If yes, what form and how often:
Any history of addiction?:
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Any other drug use?:
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Do you carry a cell phone or other wireless device on your person regularly?:
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If so, where do you carry your cell phone or other wireless device?:
What kind of case for your device(s) if any?:
List electrical devices active/known at your home/apartment (security systems, wifi, satellite, number of computers, wireless devices, etc):
List items plugged-in and active wireless devices in bedroom at night:
Do you use any devices/ways of protecting yourself from electromagnetic frequencies, radiation, etc?:
List any treatments used on yard/garden on your property, as specifically as possible, even if apartment:
List all household cleaners present in/around home/car (kitchen, bathroom, windows, etc) including brand:
List all laundry cleaning/softener products used, including brands:
List all body/beauty care products used, including brands and product name:
Use a microwave?
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Any and all known mold locations in home, however small:
Rooms with carpet in home? New or old?:
Are there nearby industrial/conventional farming or livestock operations?:
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Nearby high-voltage power lines or other high concentration of electrical current?:
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Additional Information:
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