Intake Packet

Prior to meeting with Tina, the following paperwork should be completed and submitted at least 3 Days prior to your appointment. Try to complete as much as possible as this will allow for a productive initial appointment. However, it is okay to leave a question blank if you do not know the information. 

  • What to Expect Overview

  • Disclosure Form

  • Environmental Exposure Checklist

  • Intake Form along with a separately written health history. This health history should begin when you started experiencing health issues/symptoms and should include the locations you have lived and traveled, any environmental exposures encountered (water damaged buildings, chemical or heavy metal exposures, pathogen or parasite exposures), any physical traumas/injuries/accidents along with treatments/surgeries/medications received, any stressful events/situations you’ve experienced, emotional health status, and current symptoms that may have contributed to your current health status.

  • Food Diary Instructions

  • Food Diary Form Include at least 3, but no more than 7 days of a food diary with any adverse symptoms noted. Please do not change the way you eat while tracking your food intake.

Please send completed forms to tina@root-cause-nutrition.com

 
 

AFFILIATE LINKS

Root Cause Nutrition may recommend the purchase of supplements and other wellness products. The providers below are trusted sources for these purchases and may offer discounts through relationships with Root Cause Nutrition.  

Biomat Network

DoTerra

Relax Saunas

The Gupta Program

Purchase products through our Fullscript virtual dispensary.