Sarah Banner, Intake Forms in Natrona Heights, PA | Optimal Health & Wellness Chiropractic & 24hr Fitness Center

Thank you for Joining Sarah’s Holistic Health Programs!

We are exciting for your future in a healthy new you!

We will contact you soon!

In the meantime, please fill out the intake forms below and submit them to us.

Intake Form

Name
Day Phone
Night Phone
Cell Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Relief from what top 3 symptoms
Life Goals
How much sweaty activity weekly?
What type of activity?
How many ounces of water do you drink daily?
What type?
- RO
- Tap
- Spring
- Distilled
Which meals daily eaten?
- Breakfast
- Lunch
- Supper
How many eliminations per day?
How many digestive enzymes daily?
How many breathing exercises daily?
How much of the following do you consume? (example, ID = once daily, 3M = 3 times monthly)
Soda pop Coffee Smoking Alcoholic Bev
Fast food Milk White Flour Sugar usage
Raw fruit Meat Raw Veggies Whole Grains
What types of food do you crave?
- Salty
- Chocolate
- Sweets
- Breads
What are your favorite foods?
How much daily energy (1 = lowest energy level; 10 = highest energy level) do you have?
What surgeries have you had and when?
How many hours of TV do you watch?
- Yes
- No
How many hours of spiritual enrichment each week? (Bible, prayer, church, etc.)
How many hours a week do you spend with family/friends?
How many hours of sleep do you get each night?
How many hours do you need?
What kind of prescription medication do you take?
Would you like to receive our natural health newsletter?
- Yes
- No
Who referred you for your appointment today?
I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is a personal ministry and spiritual counseling.

I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation.

The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease.
Signature
Date
MM slash DD slash YYYY
Untitled
- Acne
- ADD/ADHD
- Adrenal Glands
- Allergies
- Alzheimer's Disease
- Anemia
- Anger
- Anxiety
- Arteriosclerosis
- Arthritis
- Asthma
- Back Pain
- bad Breath
- Bed Wetting
- Bell's Palsy
- Bites
- Bladder
- Blood Pressure-High
- Blood Pressure-Low
- Boils
- Bones
- Breathing
- Bronchitis
- Bruises
- Burns
- Cancer
- Candida
- Canker Sones
- Carpal Tunnel
- Chest Congestion
- Cheat Pain
- Cholesterol
- Circulation
- Cold - Common
- Cold - Temperature
- Colic
- Colon
- Constipation
- Cough
- Cravings
- Dandruff
- Depression
- Diabetes
- Diarrhea
- Digestion
- Dizzy Spells
- Ear Infection
- Ear Ringing
- Edema
- Emphysema
- Epilepsy
- Eyesight
- Fatigue
- Fever
- Flu
- Gallstones
- Gangrene
- Gas
- Gout
- Gums
- Hair Issues
- Headache
- Heart Issues
- Heartburn
- Hemorrhoids
- Herpes
- Hiatal Hernia
- Hives
- Hormones
- Hyperactive
- Hypertension
- Hyperthyroidism
- Hypoglycemia
- Impotence
- Incontinence
- Indigestion
- Insomnia
- Joint Pain
- Kidney Stones
- Laryngitis
- Leprosy
- Leukemia
- Liver
- Lung Issues
- Lupus
- Lymph Glands
- Menopause
- Menstrual Cramps
- Migraines
- Mononucleosis
- Mucous
- Nails
- Nausea
- Nervousness
- Parasites
- Parkinson's Disease
- Perspiration
- PMS
- Pneumonia
- Polyps
- Pregnancy
- Prostate
- Psoriasis
- Rash
- Reproductive
- Respiratory
- Rheumatism
- Ring worm
- Seizures
- Shingles
- Sinus
- Skin Issues
- Snoring
- Sore Throat
- Stomach
- Stress
- Stroke
- Sty
- Teething
- Tennis Elbow
- Tonsillitis
- Tumors
- Ulcers
- Urinary Infections
- Varicose Veins
- Weight-Underweight
- Weight-Overweight
- Yeast Infections
- Other

Toxicity Test

Patient Name:
Date
MM slash DD slash YYYY
Rate each of the following symptoms based on your typical health profile for the last 30 days.
Point Scale:
0 - Never or almost never. 1- Occasionally. Effect is not severe2 - Occasionally. Effect is severe 3 - Frequently. Effect is not severe 4 - Frequently. Effect is severe

Symptoms Questionnaire
HEAD:
Headaches Faintness Dizziness Insomnia Total
EYES:
Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision Total
EARS:
Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss Total
NOSE:
Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation Total
MOUTH/THROAT:
Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, lips Canker sores Total
SKIN:
Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating Total
HEART:
Chest Pain Irregular or skipped heartbeat Rapid or pounding heartbeat Total
LUNGS:
Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing Total
DIGESTIVE TRACT:
Nausea, Vomiting Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain Total
JOINTS/ MUSCLES:
Pain or aches in joints Arthritis Stiffness or limitation of movement Feeling of weakness or tiredness Pain or aches in muscles Total
WEIGHT:
Binge eating/drinking Craving certain foods Excessive weight Water retention Underweight Compulsive eating Total
ENERGY/ACTIVITY:
Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness Total
MIND:
Poor memory Confusion, poor comprehension Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities Poor concentration Poor Physical coordination Total
MIND:
Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression Total
EMOTIONS:
Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression Total
OTHER:
Frequent illness Frequent or urgent urination Genital itch or discharge Total
GRAND TOTAL
Are you presently using prescription drugs?
- Yes (1pt.)
If yes, how many are you currently taking?
- Yes(1pt)
- No(0pt)
Are you presently taking one or more of the following over-the-counter drugs?
- Cimetidine (2pts.)
- Acetaminophen (2pts.)
- Estradiol (2pts.)
If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them:
- Experience side effects, drug(s) is (are) efficacious at lowered dose(s) (3pts.)
- Experience side effects, drug(s) is (are) efficacious at usual dose(s) dose(s) (2pts.)
- Experience no side effects, drug(s) is (are) usually not efficacious (2pts.)
- Experience no side effects, drug(s) is (are) usually efficacious (0pt.)
Do you currently use or within the last 6 months had you regularly used tobacco products?
- Yes (2pts.)
- No (0pt.)
Do you have strong negative reactions to caffeine or caffeine containing products?
- Yes (2pts.)
- No (0pt.)
Do you commonly experience “brain fog”, fatigue, or drowsiness?
- Yes (2pts.)
- No (0pt.)
Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?
- Yes (2pts.)
- No (0pt.)
- Don’t know (0pt.)
Do you feel ill after you consume even small amounts of alcohol?
- Yes (2pts.)
- No (0pt.)
- Don’t know (0pt.)
Do you have a personal history of
- Environmental and/or chemical sensitivities (5pts.)
- Chronic fatigue syndrome (5pts.)
- Multiple chemical sensitivity (5pts.)
- Fibromyalgia (3pts.)
- Parkinson’s type symptoms (3pts.)
- Alcohol or chemical dependence (2pts.)
- Asthma (1pt.)
Do you have a history of signicant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
- Yes (1pts.)
- No (0pt.)
Do you have an adverse or allergic reaction when you consume sulte containing foods such as wine, dried fruit, salad bar vegetables, etc?
- Yes (1pts.)
- No (0pt.)
- Don’t know (0pt.)
Grand Total

Sarah Banner, Intake Forms

Thank you for Joining Sarah’s Holistic Health Programs!

Intake Form

Toxicity Test

Point Scale:

Symptoms Questionnaire