Glow Protocol Intake

Glow Protocol Intake Questionnaire

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Glow Protocol Intake Form

Please take your time and carefully complete your Glow Protocol Intake Assessment on the following pages. You will be asked about your health goals, lifestyle, current symptoms, and health history so that we may better serve you on your health journey.

This assessment will take about an hour, and does not need to be completed in one sitting. Simply click “save and continue" on the bottom of each page and you will be able to come back and finish your assessment later.

Name*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation*

Hours Per Week*

DOB*

MM slash DD slash YYYY

Gender*

Male

Female

Relationship status :

Referred By :

HEALTH GOALS

What do you want to achieve with The GLOW Protocol?*

What are your top 3 goals for your health and wellness? Please be specific.*

What are your biggest challenges reaching your health and nutrition goals?*

On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following: To improve your health, how ready/willing are you to*

	1	2	3	4	5
significantly modify your diet
keep a record of everything you eat each day
take nutritional supplements each day
modify your lifestyle (ex: work demands, sleep habits, physical activity)
practice relaxation techniques
engage in regular exercise/physical activity

What have you tried in the past to achieve your health goals? This includes any diet or fitness program, coaches, supplements, books etc.*

Are you currently being treated for any medical conditions. If so, what are they and how are you being treated?*

Do you have any barriers that may impact your ability to follow a nutrition plan, supplement protocol or lifesyle changes (e.g. financial constraints, time constraints?)*

MEDICAL HISTORY

Have you or any close family members been diagnosed with an illness or condition? If so, what are they?*

List all medications you are currently taking, along with the reason for use, and dosage:*

Example: Synthroid, 75mg per day, for hypothyroidism

List any vitamins, minerals, herbal, hormone or homeopathic remedies you are currently taking and the amounts/dosages. Please include the brand:*

Example: Daily GLOW, Multinutrient, 4 capsules per day

List any known allergies (food, environmental, medications)*

LIFESTYLE

What is your typical sleep schedule and how many hours of sleep do you get per night?*

Do you have trouble falling or staying asleep?*

Yes

Sometimes

Do you awaken feeling rested?*

Yes

Sometimes

Do you experience any lulls or highs in your energy levels throughout the day? If so, at what time of day?*

Do you workout? If so, what type of exercise? How many times per week?*

On a scale of 1 (extremely low) to 10 (extremely high), how would you describe your stress levels?*

On a scale of 1 (extremely low) to 10 (extremely high), how would you describe your happiness levels?*

What are the major causes or factors of your stress?*

How does your stress manifest itself? (i.e. fatigue, irritability, anxiety, panic attacks?)*

What coping mechanisms do you use?*

Has there been any significant emotional trauma in your life (divorce, loss of a loved one, accident, abuse)? If so, please describe.*

What do you think and feel about your body? Please explain emotionally/physically.*

Do you vacation regularly? Yes/No. When was your last vacation?*

Do you have any hobbies or activities you enjoy doing?*

Do you consume alcohol or tobacco? If so, how much and how often?*

How many hours do you spend daily on average on the cellphone?*

How many hours do you spend daily on average watching television?*

How many hours do you spend daily on average in front of the computer?*

DIGESTIVE HISTORY

Do you associate any digestive symptoms with eating certain foods? Please explain.*

How often do you have a bowel movement?*

Do you take laxatives? If so, what type/brand do you take, and how often?*

Would you describe your stools as hard, soft, or loose?*

Please indicate how often you experience the following symptoms:*

	Often	Sometimes	Rarely
Heartburn
Gas
Bloating
Stomach Pain
Nausea/Vomiting
Diarrhea
Constipation

REPRODUCTIVE HEALTH (FEMALES ONLY)

Menstrual Status: Are you still getting regular periods? Do you have irregular periods? Are you in menopause?

Please pick any symptoms of hormone imbalance you experience:

Cramping

Bloating

Headaches

Mood changes

Breast tenderness

Irritability

Cravings

Hair Loss

Bone Loss

Belly Fat Gain

Acne

Dry, Saggy Skin

Hot Flashes

Insomnia

Do you get emotionally upset every month? If so, please describe (anxiety, depression, etc):

Are you still cycling? If yes, how often do you have a menstrual cycle? If you are in menopause, when was your last period?

Are you on birth control? If yes, what type, for how long and what reasons?

Are you using hormone replacement? If so, what type, and for how long? If you know your dose, please list that as well.

Have you given birth? If yes, how many times?

Have you had a miscarriage? If yes, how many?

Have you had any fertility treatments? If yes, please describe:

Could you be pregnant?

Yes

DIET HISTORY

Do you have diet restrictions or limitations for any reason (health, cultural, religious, or other)? Please list any food allergies, sensitivities, or intolerances.*

Are you currently on a special diet? Ie. Low-carb, gluten-free, FODMAP, Paleo, etc.*

Who prepares the majority of your meals? If you do, how much time do you spend cooking/preparing meals each day?*

Do you find cooking difficult?Please explain.*

Which meals do you eat regularly? Check all that apply:*

Breakfast

Lunch

Dinner

Snacks

Do you experience any symptoms if meals are missed? Explain.*

Please indicate the beverages you drink, and how often you drink them.*

List any food cravings you may have.

Do you avoid or dislike certain foods? If so, why?*

What five foods do you eat most often?*

Are there any foods you are not willing to give up?*

Describe your relationship with food (excellent, good, poor, food is your enemy). Be specific.*

Eating Style: Based on how you eat on a regular basis, please check all that apply:*

Fast eater

Erratic eater

Emotional eater

Late night-eater

Time constraints

Dislike "healthy" food

Travel frequently

Do not plan

Meals/menus

Rely on convenience

Family Members have different tastes

Love to eat

Eat too much

Eat because I have to

Negative relationship with food

Struggle with eating issues

Confused about food/nutrition

Frequently eat fast food

Poor snack choices

Please list anything else you would like us to know:

DIAGNOSIS

Please select any of the following conditions you have been diagnosed with. Check all that apply.*

Acne

ADD Or ADHD

Angina

Anxiety

Arrhythmia-Irregular Heart Rate

Asthma

Autism

Autoimmune Disease

Breast Cancer

Bronchitis

Celiac Disease

Chronic Fatigue Syndrome

Chronic Pain

Colon Cancer

Crohn’s Disease Or Ulcerative Colitis

Dementia

Depression

Diabetes

Eating Disorder

Eczema

Emphysema

Endometriosis

Environmental Allergies

Epilepsy Or Seizures

Fibrocystic Breasts

Fibroids

Fibromyalgia

Food Allergies

Frequent Urinary Tract Infections

Frequent Yeast Infections

Gallstones

GERD Or Reflux

Gout

Heart Attack

Heart Failure

Hepatitis

High Blood Fats-Cholesterol, Triglycerides

None of the Above

DIAGNOSIS (CONTINUED)

Please select any of the following conditions you have been diagnosed with. Check all that apply.*

Hyperthyroidism-Overactive Thyroid

Hypoglycemia

Hypothyroidism-Low Thyroid

Immune Deficiency

Infertility

Interstitial Cystitis

Irritable Bowel Syndrome

Kidney Stones

Lung Cancer

Metabolic Syndrome Or Insulin Resistance

Migraines

Mitral Valve Prolapse

Mononucleosis

Multiple Chemical Sensitivities

Multiple Sclerosis

Murmur

Osteoarthritis

Osteopenia

Osteoporosis

Ovarian Cysts

Parkinson’s Disease

Pelvic Inflammatory Disease

Peptic Ulcer Disease

Pneumonia

Prostate Cancer

Psoriasis

Reproductive Cancer

Rheumatic Fever

Rheumatoid Arthritis

Sexual Dysfunction

Sexually Transmitted Diseases

Sinusitis

Skin Cancer

Sleep Apnea

Stroke

Vaginal Infection

None of the Above

SIGN/SYMPTOMS

Please select any health symptoms that you regularly experience. Check all that apply.*

Acne

Agoraphobia

Anal Spasms

Angina Or Chest Pain

Anxiety

Athletes Foot

Auditory Hallucinations

Back Muscle Spasm

Bad Breath

Bad Odor In Nose

Bed Wetting

Binge Eating

Bitten Nails

Blackouts

Bloating Of Lower Abdomen

Bloating Of Whole Abdomen

Blood In Stools

Breast Cysts

Breast Lumps

Breast Tenderness

Breathlessness

Brittle Nails

Bulimia

Bumps On Back Of Upper Arms

Burping

Caffeine Dependency

Calf Cramps

Canker Sores

Can’t Gain Weight

Can’t Lose Weight

None of the Above

SIGN/SYMPTOMS (CONTINUED)

Please select any health symptoms that you regularly experience. Check all that apply.*

Can’t Remember Dreams

Carbohydrate Craving

Carbohydrate Intolerance

Cellulite

Chest Tightness

Cold Hands & Feet

Cold Intolerance

Cold Sores

Concentration Or Memory Problems

Conjunctivitis

Constipation

Cough-Dry

Cough-Productive

Cracking At Corner Of Lips

Curved Up Nails

Dark Circles Under Eyes

Daytime Sleepiness

Decreased Libido

Dentures With Poor Chewing

Depression

Diarrhea

Difficulty Concentrating

Difficulty Falling Asleep

Difficulty Swallowing

Difficulty With Balance

Difficulty With Judgment

Difficulty With Memory

Difficulty With Speech

Difficulty With Thinking

Discharge From Penis

None of the Above

SIGN/SYMPTOMS (CONTINUED)

Please select any health symptoms that you regularly experience. Check all that apply.*

Distorted Sense Of Smell

Distorted Taste

Dizziness Or Spinning

Dry Mouth

Dryness Of Skin, Scalp Or Hair

Ear Fullness

Ear Pain

Ear Ringing Or Buzzing

Early Waking

Ears Get Red

Easy Bruising

Eczema

Ejaculation Problem

Enlarged Neck Lymph Nodes

Eye Crusting

Eye Pain

Eyelid Margin Redness

Fainting

Fatigue

Fearfulness

Fever

Fissures

Flushing

Foods Repeat-Reflux

Foot Cramps

Frayed Nails

Frequent Dieting

Fungus On Finger Nails

Fungus On Toe Nails

Hay Fever: Change Of Season

Hay Fever: Fall

None of the Above

SIGN/SYMPTOMS (CONTINUED)

Please select any health symptoms that you regularly experience. Check all that apply.*

Hay Fever: Spring

Hay Fever: Summer

Headaches

Hearing Loss

Hearing Problems

Heart Murmur

Heartburn

Heat Intolerance

Hemorrhoids

Herpes-Genital

High Blood Pressure

Hives Or Urticaria

Hoarseness

Impotence

Infection

Intolerance To All Dairy Products

Intolerance To Corn

Intolerance To Eggs

Intolerance To Fatty Foods

Intolerance To Gluten-Wheat

Intolerance To Yeast

Irregular Pulse

Irritability

Itching Of Skin Or Scalp

Jock Itch

Joint Deformity

Joint Pain

Joint Redness

Joint Stiffness

None of the Above

SIGN/SYMPTOMS (CONTINUED)

Please select any health symptoms that you regularly experience. Check all that apply.*

Kidney Disease

Kidney Stone

Lackluster Skin

Lactose Intolerance

Leaking Or Incontinence

Light-Headedness

Liver Disease Or Jaundice-Yellow Eyes Or Skin

Low Body Temperature

Lower Abdominal Pain

Lumps In Testicles

Menstrual Cramps

Menstrual Heavy Periods

Menstrual Irregular Periods

Menstrual No Periods

Menstrual Scanty Periods

Menstrual Spotting Between

Migraine

Moles W Color Or Size Change

Mucus In Stools

Muscle Pain

Muscle Spasms

Muscle Stiffness

Muscle Twitches-Arms Or Legs

Muscle Twitches-Eyes

Muscle Weakness

Nasal Stuffiness

Nausea

Neck Muscle Spasm

Night Waking

Nightmares

None of the Above

SIGN/SYMPTOMS (CONTINUED)

Please select any health symptoms that you regularly experience. Check all that apply.*

Nose Bleeds

Numbness

Oily Skin

Other Enlarged Or Tender Lymph Nodes

Other Phobias

Pain Or Burning

Pale Skin

Palpitations

Panic Attacks

Paranoia

Passing Gas

Patchy Dullness

Periodontal Disease

Phlebitis

Pitted Nails

Poor Appetite

Poor Libido–Low Sex Drive

Post Nasal Drip

Ragged Cuticles

Rash

Red Face

Ridged Nails

Salt Cravings

Seizures

Sensitive To Bites

Sensitive To Poison Ivy Or Oak

Sensitivity To Auto Exhaust Fumes

Sensitivity To Cigarette Smoke

Sensitivity To Loud Noises

None of the Above

SIGN/SYMPTOMS (CONTINUED)

Please select any health symptoms that you regularly experience. Check all that apply.*

Sensitivity To Perfume Or Colognes

Shingles

Sinus Fullness

Sinus Infection

Skin Darkening

Snoring

Soft Nails

Sore Throat

Sore Tongue

Strong Body Odor

Strong Stool Odor

Suicidal Thoughts

Sweet Cravings

Swollen Ankles Or Feet

Tender Neck Lymph Nodes

Tendonitis

Tension Headache

Thick Calluses

Thickening Of Finger Nails

Thickening Of Toenails

Tingling

TMJ Problems

Tooth Pain

Tremor Or Trembling

Undigested Food In Stools

Upper Abdominal Pain

Urgency

Urinary Hesitancy

Urinary Infection

Vaginal Discharge

Vaginal Itch

Vaginal Odor

Vaginal Pain

Varicose Veins

Vision Problems

Visual Hallucinations

Vitiligo

Vomiting

Wheezing

White Spots Or Lines On Nails

Winter Stuffiness

None of the Above

FAMILY HISTORY

Please check any condition that you runs in your family or that affects your parents, siblings, aunts, uncles and grandparents*

Anxiety Fhx

Arthritis Fhx

Dementia Fhx

Depression Fhx

Diabetes Fhx

Heart Disease Fhx

Irritable Bowel Syndrome Fhx

Obesity Fhx

Psychiatric Disorders Fhx

None of the Above

TOXIC EXPOSURE

Please check any toxin that you have been exposed to or continue to be exposed to*

Carpets Or Rugs

Chemicals

Cleaning Chemicals

Damp Environments

Electromagnetic Radiation

Frequent Airplane Travel

Harsh Chemicals-Solvents, Glues, Gas, Acids Etc.

Heavy Metals-Lead, Mercury, Etc

Mold

Old Paint

Paints

Pesticides Or Herbicides

Renovations

Smokers

Stagnant Or Stuffy Air

Water Leaks

Animals Inside Home

None of the Above

MEDICATION

Medication*

Albuterol

Amoxicillin/Antibiotics

Anti-anxiety medications

Antidepressants/ SSRIs

Birth Control Patch

Birth Control Pills

Blood pressure medication/ACE Inhibitors

Hormone Replacement Therapy

Melatonin

NSAIDs

Pain medication

Prednisone

Proton Pump Inhibitors

Statins

Thyroid medication

Tylenol

None of the Above

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Glow Protocol Intake Questionnaire