New Client Intake Form You are here: Home / New Client Intake FormPlease complete and submit form after you have scheduled your appointment. To schedule an appointment, please fill out the contact form. Required fields noted with an asterisk (*). Step 1 of 7 14% Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Email* Enter Email Confirm Email Cell Phone*Home PhoneBirthdate* MM DD YYYY Client is a*MaleFemaleChildChild resides withMotherFatherBothWeight*Please enter a value greater than or equal to 1.Height*Age*Occupation*How did you hear about us?* DISCLAIMER The advice and opinions provided by Teri Cochrane are based on her education, training and experience. Teri Cochrane, Teri Cochrane S LLC, Healing Paths LLC and Teri Cochrane - Beyond Nutrition expressly disclaim all responsibility for any liability, loss, claim, damage or risk, personal or otherwise, which may be incurred as a result of any recommendation for any dietary or lifestyle change, including the use of dietary supplements. Bio-individualized nutritional counseling is not intended as medical advice, nor should it be used as a substitute for medical care administered by a physician or other licensed health care provider. Any and all appointments and interactions with Teri Cochrane, Teri Cochrane—Beyond Nutrition or Healing Paths LLC are on an at-will basis, and either party may terminate the professional consulting relationship at any time. During the course of your appointment, Teri Cochrane and/or other nutritional professionals may touch you with gentle pressure to perform proprietary muscle testing using applied kinesiology. Our methodology has not been evaluated by the Food and Drug Administration. Our program and the individual counseling services provided are not intended to diagnose, treat, cure, or prevent any disease. Before making any complex health-related decisions, please consult your physician or other licensed healthcare provider. We are committed to maintaining client confidentiality and protecting the security of personal information you provide to us by following industry best practices for internet security. We are not required to and currently do not operate under federal Health Insurance Portability and Accountability Act (HIPAA) compliance standards. Policies, Procedures and Fees Health Insurance Claims As we are not a medical practice, we do not participate or coordinate with any health insurers. If your insurance (including Flexible Spending Account or similar program) covers services and/or supplements such as those provided by our office, please work with your primary care provider directly to assist you with filing insurance claims. Appointment Cancellation and Fees We require a $175 deposit at the time of booking to secure a new client initial consultation. We will confirm your appointment one week and again two (2) days before the date of service via text messages and phone. If you are unable to make your Initial Consultation and do not notify our office at least two (2) business days in advance of your appointment, we will retain your $175 deposit as a “No Show Fee.” In the case of Follow-up appointments, you will be assessed a cancellation fee of $100 to the credit card on file. Please contact the office at 703-435-8193 or [email protected] to make, change or cancel an appointment Late Arrival for Consultations To preserve the quality of our care for you and in consideration to our other clients, if you do not arrive within 15 minutes of your scheduled appointment time, we regret that you may not be able to be seen that day and you will be assessed a cancellation fee of $100. Privacy Policy Terms of Service Acknowledge Terms*By completing and submitting this form and providing your electronic signature, you acknowledge and agree to the above Disclaimer as well as our Policies, Procedures and Fees; Privacy Policy and Terms of Service: Reason for Visit to Teri Cochrane*How long have you had these conditions?Have you received medical treatment for these conditions?YesNoWhat treatment have you received for these conditions?Other medical conditionsPast medical conditions or recurring infectionsPlease list your current health care providers or medical practitioners.Blood TestsDate of Last Physical Exam Total CholesterolLDLHDLTriglyceridesTSHThyroid Stimulating HormoneT3TriiodothyronineALT/ASTBlood PressureFasting Glucose or HA1cFasting Glucose or HA1cAttach any pertinent lab results here. Drop files here or Current Medications / Supplements, including Herbal and OTC MedicationsPlease list any supplements or medications you are currently taking here, or bring them to your consult with you.Type, Dosage and DurationType, Dosage and DurationType, Dosage and Duration HistoryWhere were you born and raised?Where was your child born and raised?What is your ethnic background?What is your child's ethnic background?Have you or any of your family members experienced any of the following conditions?Diabetes Self Family Alzheimer's Disease Self Family Hypoglycemia (low blood sugar) Self Family Hyperglycemia (high blood sugar) Self Family Rheumatoid Arthritis Self Family Osteoarthritis Self Family Gall Bladder Issues Self Family Gout Self Family Crohn’s Disease Self Family IBS Self Family Anxiety Self Family Depression Self Family Fibromyalgia Self Family POTS Self Family Chronic Fatigue Self Family Swelling Self Family High Blood Pressure Self Family Ulcerative Colitis Self Family Candida Self Family Strep Self Family Asthma Self Family High Cholesterol Self Family Cardiovascular Disease Self Family Kidney Disease Self Family Epstein Barr Virus (EBV) or Mononucleosis Self Family Lyme Disease Self Family HSV (Herpes Simplex) Viruses Self Family Have you ever been diagnosed with cancer?If so, what kind and how was it treated?Alopecia Self Family History of Addiction Self Family Are you regularly exposed to cigarette smoke or second-hand smoke?YesNoIf you smoke, how many per day?What is your weekly alcohol consumption?Less than 1 drink2-4 drinks5 or more drinks Check the boxes if the statements below apply to you.Medical History My birth mother was exposed to well water. My parents have lived on a military base. My birth mother had a hysterectomy. Costume jewelry stains my skin or makes it itch or make my ears itch. I have suffered from ear infections. I have had strep throat. I had or currently have eczema. I have seasonal allergies or chemical sensitivities. I had or currently have acne. I have warts. I have had toenail fungus/athletes foot/jock itch. I have itchy ears. I have or have had Vitiligo. I have or have had rectal itching. I have dandruff or Psoriasis I have had allergy shots. I had the flu shot this season. How long have you had allergy shots? I'm prone to yeast infections. Age of first menstruation?Are your periods regular?YesNoAre your periods heavy?YesNoAre your periods painful?YesNoWhat are the average number of days from cycle to cycle? I am currently on Birth control. Mother’s PregnancyPregnancyGeneral health during pregnancyGoodFairPoorPregnancy Complications The mother had gestational diabetes during pregnancy. The mother had preeclampsia during pregnancy. The mother had strep while pregnant. The mother had other complications while pregnant. The mother used antibiotics while pregnant. The mother used steroids while pregnant. The mother had a C-Section delivery. Please list hereWas your child delivered vaginally or by C-section?VaginallyC-SectionAt what week was your child delivered?Child History My child was breast-fed. My child was formula-fed. My child was delivered via C-Section. My child has been exposed to well water. My child has lived on a military base. My child's parents have lived on a military base. My child's mother has been been a strep carrier. My child's mother had a hysterectomy. My child suffers from ear infections. My child has had tubes in his/her ears. My child has had strep throat. My child has had Mononucleosis/Epstein Barr Virus (EBV). My child has had Lyme disease. My child has had tonsillitis. My child has had eczema. My child has allergies. My child takes allergy medication. My child has had allergy shots. My child has had warts. My child has had yeast infections or complained of irritation. My child has had toenail fungus. My child has dandruff or itchy ears. My child has had asthma. My child has rectal itching My child coughs at night. Our home has a humidifier. My child has had the flu shot this season. How long was your child breast-fed?What kind of formula? List here:How frequently do ear infections occur?At what age did your child have tubes in the ears?What kind of allergy medicine does he/she take? List here:How long has your child had allergy shots? My child has used steroids for asthma. How many bowel movements a day does your child have, on average?My child's stools are Formed. Light colored. My child tends to be constipated. My child tends toward loose stools or diarrhea. My child has/had parasites. My child's stools are greasy. My child's stools float. My child's stools are pencil-thin. My child has/has had diverticulitis. My child has/had colitis. My child has/had GERD or Acid Reflux. My child has pain in thier stomach when they eat. My child bloats after eating. CURRENT HISTORYGas/GI I have daily bowel movements. How many bowel movements a day do you have, on average? They are formed. They are light colored. I tend to be constipated. I tend towards loose stools or diarrhea. I have had parasites. My stools are greasy. My stools float. My stools are pencil-thin. I have diverticulitis. I have had colitis. I am on antacids. I have/had GERD or Acid Reflux. I am on/have taken protein-pump inhibitors. I commonly experiencing burping. I have had hives. I have bumps on the back of my upper arms. My mouth tingles or throat itches when I eat certain foods. I have pain in my stomach when I eat. I bloat after eating. I have had ulcers. I have been diagnosed with h-pylori. I have had gallstones. I have had my gallbladder removed. I have had my appendix removed. My child has daily bowel movements.YesHow many bowel movements a day does your child have, on average:Please enter a value between 0 and 99. They are formed. They are light colored. My child tends to be constipated. My child tends towards loose stools or diarrhea. My child's stools are pencil-thin. My child has had hives. My child has pain in his/her stomach after eating. My child wets the bed. My child has a history of intestinal parasites. Kidneys I have had kidney stones. I swell easily. I have edema. My urine color is dark. I have a low daily urine output. I experience frequent urination or urinary urgency. I take blood pressure medication. I take cholesterol medication. I have had hepatitis. My urine has an odor when I eat asparagus. I have suffered from tachycardia. I have suffered from bradycardia. I have/have experienced tingling/numbness in my extremities. I have trouble building muscle. I have had protein in my urine. I have had non-menstrual blood in my urine. Kidney stonesIf you answered yes to the above question, what kind of stones did you have (Calcium oxalate, Struvite stones, Uric acid, Cystine, etc.) ?How much water do you drink during the day?How many ounces?Neurological FunctionDo you have difficulty with your memory or trouble focusing?Have you ever had a concussion?Adrenals I suffer from allergies. I take antihistamines. I use nasal sprays. I take bronchial dilators. I am currently taking steroids. I sleep through the night. I frequently wake up between 2 and 4 am. I frequently wake up between 3 and 5 am. I wake up and have trouble falling asleep. I have night sweats. I have suffered from AD(H)D. I have used steroids. I have used antibiotics. What kind of steroids are you taking? List here:How many hours do you generally sleep each night?Endocrine I suffer from low libido. I have trouble with building muscle. I get lightheaded. I get shaky which eating relieves. I have food cravings. I am frequently tired or feel low-energy. What foods are you craving? List here: I am on bio-identical hormones. I am on Hormone replacement therapy (HRT). I get lightheaded. I have had fibroids. I have had polycystic breasts. I have had ovarian or uterine cysts. I have had a hysterectomy. Which bio identical hormones? List here:How long have you been taking either bio-identical or HRT? I have children. I have had miscarriages. List how many children you have and their genders:Did I deliver vaginally or by C-section?VaginallyC-Section I nursed my children. I have had trouble conceiving. I have had preterm labor. I have had gestational diabetes. I have had preeclampsia during pregnancy. I have been on bed rest during pregnancy. I have been strep-positive during pregnancy. I had excessive morning sickness during pregnancy. I have had edema or swelling during pregnancy. Liver I have/had fibroids. I have/had polycystic breasts. I have/had ovarian or uterine cysts. I have/had trouble clearing or an adverse reaction to anesthesia. Relatively little caffeine makes me jittery or nervous. It takes a lot of caffeine or other substances to affect me. I have a sensitivity to strong smells or chemicals. Alcohol seems to affect me differently than others. Coffee makes my urine smell differently. Thyroid I am on thyroid medication. My fingernails break easily. I tend to get cold easily. I tend to run hot during the day. I tend to have hot flashes. My heart races. I tend to carry my weight around the mid-section. I have trouble gaining weight. I have trouble losing weight. AllergiesWhich foods are you allergic to? List here:Which environmental allergens affect you? List here:Which medicines are you allergic to? List here:Which foods are he/she allergic to? List here:Which environmental allergens affect your child? List here:Which medicines are he/she allergic to? List here:Growth and SkinDid your child ever fall off the growth chart?YesNo My child was diagnosed as a failure to thrive baby. My child has had bumps on the backs of their arms or legs. My child’s average body temperature is below 98 degrees. Vaccinations My child has received all the vaccinations up to date. We have followed the standardized vaccination schedule. My child has had a reaction to vaccinations. What was was the reaction? List here:Sleeping Patterns My child has problems falling asleep. My child has problems staying asleep. How many hours of sleep does your child get on average?Neurological My child has trouble focusing at school. My child is hyperactive. Have you noticed when these things get better or worse? List here: Food Habits:Dietary Choices I am a vegetarian. I am a vegan. I do not eat red meat. I am a pescatarian. I eat breakfast. Describe a typical breakfast:Describe a typical lunch:Describe a typical dinner: I snack during the day. Describe a typical snack:Do you drink caffeinated beverages? Coffee Tea Soft Drink Green Tea Dietary Choices My child is a vegetarian. My child is a vegan. My child does not eat red meat. My child is a pescatarian My child eats breakfast regularly. Describe a typical breakfast:Describe a typical lunch:Describe a typical dinner: My child eats snacks during the day. Describe a typical snack: My child has food he/she doesn't like (food aversions). What are they? My child craves sugar. My child frequently eats pasta, breads, or cereals. My child drink soft drinks. My child frequently eat candy. What kind of soft drinks does he/she drink?Mind Body I have a mindfulness or meditation practice. I actively engage in activities that help me de-stress. I have hobbies. I exercise. How often do you engage in a mindfulness practice?How often do you engage in activities that help alleviate your stress?What are your hobbies?What kind and how many days a week do you exercise?How would you rate your current energy levels throughout the day?*