The intake form is an important first step towards your assessment.

You have two options:

You can view and print the Intake Forms (PDF) to fill them out. The paediatric section near the end are only necessary for clients 12 and under.

Or, proceed to the online form below. Please complete in one sitting or you will lose the information and have to start again. It will take about 30 minutes depending on how much detail you need to provide.

Intake Form Marina Andrawos RHN

Step 1 of 7 - Contact Information

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Instructions
Please complete all pages as truthfully and completely as possible. When a question appears more than once, please answer the question again as different sections of the overall form are interrelated.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date fo Birth*
MM
DD
YYYY
Daytime Phone*
Evening Phone*
Email*
Enter Email Confirm Email

Save and Continue Later

What are your main health concerns?*
Have you been diagnosed with any health conditions?*
Have you made any lifestyle changes (diet, exercise etc.) to help with your health concern? If so, list any changes:*
Regarding food and lifestyle, are there any changes that you haven’t made but believe you should?*
Regarding food and lifestyle, is there anything you believe you have tried to or should try to avoid?*
What obstacles or challenges are you experiencing when making food and lifestyle changes?*

Save and Continue Later

Intake Forms

Marina Andrawos

The intake form is an important first step towards your assessment.

You have two options:

Intake Form Marina Andrawos RHN

Step 1 of 7 - Contact Information

Instructions

Symptoms and Activities

GENERAL LIFESTYLE QUESTIONS:

FEMALES:

MEDICAL HISTORY:

DIETARY HABITS:

THE INTESTINAL SYSTEM

You have completed your intake form.