Intake Form - Nutritious Vitality

Sarah Horgan
PO Box 53
Woodcroft
S.A. 5162
PH: 0413746914
ABN: 74743532594

Please fill in all the information as accurately as possible. The information you provide will assist in formulating a complete health assessment. All answers are confidential.

Ideal Weight ( kgs )

Blood Type ( if known )

EMERGENCY CONTACTS ( 2 required )

Are you currently under the care of a healthcare professional?

Y N

Reason for visit and what do you hope to gain from your consultation?

Main Presenting Complaint/s:

Have you sought previous treatmentfor this? If YES provide details.

If needed, how willing and able are you to make changes to your diet and lifestyle?
( 1 being a struggle and 10 being very committed )

What barriers will prevent you from making these changes?

Any known allergies or intolerances:

Any major surgeries:

Antibiotic use ( how often ):

Medical history ( list childhood illnesses, illnesses past or present as an adult ):

FAMILY HEALTH HISTORY:

DIETARY AND LIFESTYLE HABITS:

Food Diary of a Typical Day

How much water do you drink a day?

Do you exercise regularly? If so what types of activities are you involved in?

I have answered all questions above correctly and honestly, knowing that this is in my best interest to allow my nutritionist to work to identify and rectify the underlying origins of my signs and symptons. I understand that Sarah Horgan is a nutritional medicine practitioner who will not provide a medical diagnosis. She will work within her scope of practice to provide me a personalised dietary and treatment plan to assist me with my health concerns.
I understand that all my health records are private and confidential and will stay within the practice.
I agree to the above terms.

Sarah Horgan
PO Box 53
Woodcroft
S.A. 5162
PH: 0413746914
ABN: 74743532594

Nutritional Medicine Client Consultation Card

Copyright 2025 © All rights Reserved. Nutritious Vitality

How healthy is Your Gut?

Take the Healthy Gut Quiz

To get

20%

off your first visit

Have you taken antibiotics recently?

Do you consume diet drinks and artificial sweeteners?

Do you drink alcohol?

Do you eat a diet that is high in processed foods?

Do you struggle to keep the weight off?

Do you regularly feel highly stressed, anxious and overwhelmed?

Do you suffer from any skin issues? (Rosacea, acne, hives, psoriasis, dermatitis, skin rashes)

Stress affects your bowel movements?

Do you regularly experience bloating after a meal or at the end of the day?

How often do you get sick?

How often do you exercise?

How often do you eat sugar?

Bowel Habits?

How would you describe your energy levels?

Sarah Horgan PO Box 53 Woodcroft S.A. 5162 PH: 0413746914 ABN: 74743532594

Nutritional Medicine Client Consultation Card

Copyright 2025 © All rights Reserved. Nutritious Vitality

How healthy is Your Gut?

Take the Healthy Gut Quiz

To get

20%

off your first visit

Have you taken antibiotics recently?

Do you consume diet drinks and artificial sweeteners?

Do you drink alcohol?

Do you eat a diet that is high in processed foods?

Do you struggle to keep the weight off?

Do you regularly feel highly stressed, anxious and overwhelmed?

Do you suffer from any skin issues? (Rosacea, acne, hives, psoriasis, dermatitis, skin rashes)

Stress affects your bowel movements?

Do you regularly experience bloating after a meal or at the end of the day?

How often do you get sick?

How often do you exercise?

How often do you eat sugar?

Bowel Habits?

How would you describe your energy levels?

Sarah Horgan
PO Box 53
Woodcroft
S.A. 5162
PH: 0413746914
ABN: 74743532594