Client Intake Form

Phone Consultation with
Kristina Amelong, CCT, CNC

Client Intake Form

Secure Client Intake Form

I am happy to help you with any part of your healing program! By submitting this secure intake form, you are setting your intention to have a phone consultation with me, Kristina Amelong, at a charge of $2.25 per minute.

IMPORTANT! Please ensure that you have a stable internet connection when completing this online form, especially if you will invest time in providing detailed responses. (A partially completed form cannot be saved.)

Any supporting documents can be attached at the bottom of this form if desired.

The Optimal Health Network respects the privacy of its clients. All personal information provided on this secure form will be held in strict confidence and will not be released to any third party without prior written authorization.

* First Name: (required)

* Last Name: (required)

* Your E-mail: (required)

* Confirm E-mail: (required)

If you are not already subscribed to OHN's e-newsletter, may I sign you up?
Enter YES or NO. (required)

* Phone: (required)

* Are you an international client? Enter YES or NO. (required)

International clients only: How would you prefer to call Kristina? Check one:

WhatsApp AudioFaceTime AudioStandard Phone Call

* Is this your first time having a consultation with Kristina? Enter YES or NO. (required)

* Street:
* City: * State: * ZIP:
Country (if outside USA):
(mailing address required)

* Date of Birth: (required)

Occupation:

Weight: Height: Blood Type:

Blood Pressure:

Cholesterol Levels:

How many times per day do your bowels move?

* What health challenges are you currently struggling with? For returning clients, what has or has not changed since your last appointment? (required)

Foods you generally eat in an average 48-hour period:

Breakfast: (required)

Lunch: (required)

Dinner: (required)

Snacks: (required)

How often do you cook for yourself? (required)

What oils do you include in your diet? (required)

List all vitamins, minerals, supplements and herbs that you currently take: (required)

How much water do you consume daily? (required)

Other beverages regularly consumed: (required)

PLEASE NOTE: The remaining sections of this form are all OPTIONAL. Complete only the sections that you feel are relevant to your consultation.

Check all of the following challenges you have now or have had in the past:

ArthritisBad BreathBloating/GasChemical SensitivitiesCold Hands/FeetColon ProblemsDepressionFatigueFrequent Colds/FluHeadachesHeartburnHeart PalpitationsHemorrhoidsIrritabilityLow Blood SugarNauseaPMSRectal ItchingSinus InfectionsSwollen GlandsTeeth GrindingUrinary Infections

How did you hear about the Optimal Health Network?

Health benefits you are seeking:

Describe any of the following if relevant:

Addictive struggles:

Joint/muscle aches and pains:

History of antibiotic use:

Rash/eczema/skin problems:

Surgery:

Allergies/asthma:

Food cravings:

Yeast problems:

Intestinal troubles:

Perceived brain and mind health (history of TBI or concussions):

Health of your nervous system:

Therapies you've tried for any of the challenges listed above:

Exercise regimen (type and frequency):

Describe your adolescence in a few words:

Describe any past or current exposure to toxins that you are aware of:

List all over-the-counter and prescription medications that you currently take:

What are the major stresses in your life and how do you deal with them?

Describe your sleep patterns. What hours of the night do you sleep, do you wake up frequently, etc?

Are you highly knowledgeable about your inner microbiome?

List any history with enemas and/or suppositories:

Check all of the health challenges you would like help with:

DietDeep Tissue CleansingFertility IssuesFastingAddictionWeight LossWeight GainOther (describe below)

Are you initiating this consultation in conjunction with a Hair Tissue Mineral Analysis (HTMA)? Enter YES or NO.

(OPTIONAL, BUT HIGHLY ENCOURAGED)

Using the button below, please attach a current photo of yourself, which can help me assess your state of health!

Maximum file size: 3MB

PERMITTED FILE TYPES: jpg, jpeg, png, gif, pdf, doc, docx

PLEASE NOTE: Maximum file size permitted is 3MB. If you are unsure whether an attachment exceeds 3MB, please do not attach, as it may prevent the form from being submitted successfully. You can also email your photo to me at kristina@ optimalhealthnetwork.com.

(OPTIONAL)

Using the buttons below, please attach any relevant supporting documents below.

NOTE: OHN Hair Tissue Mineral Analysis (HTMA) test results do NOT need to be submitted with your intake form.

PERMITTED FILE TYPES: pdf, doc, docx, txt, xls, xlsx, odt, ppt, pptx, jpg, jpeg, png, gif

PLEASE NOTE: Maximum file size permitted is 3MB per attachment. If you are unsure whether an attachment exceeds 3MB, please do not attach, as it may prevent the form from being submitted successfully. You can also email any supporting documents to me at kristina@ optimalhealthnetwork.com.

IMPORTANT:

Submission of this form may take up to 30 seconds after the Submit button is clicked. Thanks for your patience. Please do not refresh the page or use the back button!