Interlude in Vermont

“INTERLUDE” NOURISHMENT CLEANSE HEALTH INTAKE FORM

Thank you for taking the time to complete this questionnaire. Your answers will help me get to know you before you start your cleanse and allow me to better support you during the cleansing process.

You may complete the form electronically and return it to me by email, or print it out and mail it back to me.

Email: [marcyohm@gmail.com ]
Address: [129 Rockport Road Weston, Ma 02493]

First Name:

Last Name:

Address 1

Address 2:

City:

State:

Zip Code:

Country:

Telephone (W):

Telephone (H):

Telephone (Cell):

Email:

Birthdate

Age:

Children:

Marital Status:

Occupations:

How did you find out about The Heart of Nourishment cleanse?

Have you ever done a cleanse or fast before? For how long? Please describe your experience.

Do you exercise regularly? What type of exercise and how often?

Do you do any stress reduction, relaxation, or mind/body practices such as meditation, yoga, prayer, journal writing, etc.?

Are there any medical or psychological/emotional conditions we should be aware of—e.g., allergies, candida, IBS, depression, anxiety, etc.?

Are you experiencing any particularly stressful situations in your life right now, such as the recent loss of a loved one, job transition, or relationship or family challenges?

Is there anything else you would like to share with me?

FOOD SURVEY

Please check all of the following statements, being careful to use the appropriate box related to the frequency of your personal habits.

“FREQUENT” = at least once per day;
“OFTEN” = several times a week;
“OCCASIONAL” = once a week or less;
“SELDOM” = once or twice a month or less;
“NEVER” = almost total avoidance.

Frequent(F) Often(Of) Occasional(OC) Seldom(S) Never(N)

	Alcoholic beverages
	Eat out (restaurants, cafés, delis)
	Protein bars
	Cookies, candies, ice cream, chocolate, and other sweets
	Muffins, doughnuts, pastries
	Colas or other soft drinks
	Fruit juice (including orange juice)
	Cold breakfast cereals
	Whole grain hot cereals (e.g., oatmeal)
	Caffeine drinks (coffee, tea, hot chocolate)
	Potato chips, corn chips, pretzels

Check the ones you use:

olive oil
canola oil
corn oil
vegetable oil
butter

Check to indicate you eat and then designate type:

Meat (beef or veal, pork or ham, lamb, liver)

Chicken, Turkey

Fresh fish

Check to indicate you eat:

Fresh raw fruit
Fresh vegetables, raw or cooked
Salads
Whole grains
Whole grain breads and flour products (bagels, pasta, etc.)
White bread or white flour products (bagels, pasta, etc.)
Beans and legumes (lentil, kidney, chickpea, etc.)

Check the ones you use:

Yogurt (plain or flavored)

Milk or soymilk

Cheese

Eggs

Salt, tamari

Herbs, fresh and dried, or spices

tap, filtered, bottled: Water How much a day?

Indicate Any or All that Apply:

Eat excessively if bored or depressed

Swallow food before chewing well

Hurried or rushed meals

Sneak or hide food

Overeat

Interlude Holistic Counseling
Marcy Balter
129 Rockport Road, Weston, Ma. 02493

Interlude
Marcy Balter
Kripalu Board Chair
www.interludevt.com
781-235-1450
marcyohm@gmail.com