Intake Form | Lisa's Counter Culture

This form is for established new patients. If you new and want to learn more about working together, please fill out the Book a 15 Min Chat form first. Complete each section, allowing yourself time to think about each question. If you do this process by yourself in a quiet place, considering each question without rushing, you may remember a lot more.

Step 1 of 7

What time do you typically:
Please answer the following questions.
11.a Wake up in the morning?*
11.b Eat breakfast?*
11.c Eat lunch?*
11.d Eat dinner?*
11.e Go to bed?*
12. How often do you have a bowel movement ? Do you experience constipation or diarrhea?*
(multiple times a day, once a day, every 2-3 days, once a week)
13. How much water do you drink daily? What type of water do you drink ?*
(tap, bottled, filtered, distilled, well)
14. How often do you drink caffeinated beverages? What happens if you don’t drink them?
(coffee, energy drinks)
15. List all hormones that you are currently taking and the dosage – such as Estrogen, Progesterone, Testosterone, Pregnenolone, DHEA, Melatonin, and Thyroid. Please include dose, form (oral/topical) and how long you have been taking it*
(prescription and non-prescription / synthetic and bioidentical) also Include birth control pills and HRT
16. Have you ever used a bioidentical hormone cream (prescription or non-prescription) with Estrogen, Progesterone, Testosterone, or DHEA? If yes, then how long ago did you last use it?*
(currently using, days ago, weeks ago, months ago, years ago, etc)
17. List all other prescription medications you currently take?*
Include Brand/Dose/Frequency/Why you are taking it and for how long have you been taking it? (i.e. statins, blood pressure medication, bone loss drugs, etc.)
18. Please list all over-the-counter medications you currently use on a regular basis?*
Include brand/dose/frequency/reason for taking it?/How long have you been taking it (aspirin, Tylenol, ibuprofen, heartburn/GERD medications, topical cortisone cream, etc.)
19. Please list all nutritional supplements you currently take. Please include brand name, dosage, reason why you are taking it and for how long have you taken it?.*
(vitamins/minerals, fish oil, amino acids, probiotics, herbs, etc.)
20. Please list any food, spice, chemical, or medication to which you have had an adverse reaction?*

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Waiver
Welcome to Lisa’s Counter Culture. This handout summarizes important information that you should know about my services and provides me with your written consent assisting you on your health journey. I ask you to read it carefully, ask any questions that you may have, and then sign, date and return the form to me.
The information and opinions by Lisa Herndon or Lisa’s Counter Culture, and all related notes, workshops, coaching and other products, are intended for informational purposes only. Lisa’s Counter Culture does not claim responsibility to any person or entity for any liability, loss, or damage caused or alleged to be caused directly or indirectly as a result of the use, application, or interpretation of the information presented herein.

This information is not meant to replace medical advice of any kind. The U.S. Food and Drug Administration have not evaluated the information presented herein, and it is not intended to diagnose, treat, cure, or prevent any disease. Full medical clearance from a licensed physician should be obtained before beginning or modifying any diet, exercise, or lifestyle program.

I am not a licensed medical physician. The idea behind nutrition is that when properly grown and prepared foods and the nutrients found in foods can be supportive of health and enhance the quality of life and well-being.
- Diet and nutrition evaluation
- Functional Diagnostic Labs
- Individualized dietary recommendations based on your lifestyle and environment
- Education and research of your health concerns
- Health support complementary to that provided by licensed professionals.
Confidentiality
Your shared health information and records on file with Lisa’s Counter Culture are treated as confidential records and will only be released pursuant to your authorization or as otherwise permitted or required by law.
Patient’s Responsibility
Patients are expected to honestly answer the Client Intake Form and provide a full and accurate health history to Lisa’s Counter Culture at the time of their consultation. Clients are expected to pay at the time of service and provide all needed documents before or at the appointment.

I have read and understand the above disclosure about the services offered by Lisa Herndon. I understand that Lisa Herndon may provide me with information concerning the use of food, supplements, herbs, cooking techniques that affect my health and well-being. I understand that the use of this information is at my own risk and that any liability from the use of food, supplements and herbs are expressly disclaimed.
Agreement to Receive Electronic Disclosures & Information*
By continuing with this online application process, you agree that we may provide you this Agreement & Disclosure and any revisions and amendments to this Agreement & Disclosure in electronic form; and that, if you choose to accept the Agreement & Disclosure, you are consenting to enter into and are entering into an Agreement electronically that will govern all future transactions you conduct using the online services and agree to be bound by its terms.

From time to time, we may deliver certain information to you that is required by law or regulation to be provided to you in writing, or regarding information about our online services. By selecting the "I Agree" button below, you agree that we may provide you revisions and amendments to this Agreement & Disclosure and such other information, including but not limited to this Agreement & Disclosure or otherwise as a part of the online services. If you wish to withdraw consent to receive Information electronically, to terminate the services, or to update your information, such as a change of address or email address, send a email to "lisa@lisascounterculture.com".

You may print and retain a copy of this Agreement & Disclosure or any future information sent to you electronically. You may also obtain a free copy of this Agreement & Disclosure, any amendments to it, and other communications about the Service in paper form by writing or calling us at the above address and telephone number.
- I Agree
Date*
MM slash DD slash YYYY
Name*
First Last
Email*
This is required to send you a copy.
Enter Email Confirm Email

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Step 1 of 7

Health History Information

What time do you typically:

Women Only

Men Only

Section Break

Waiver

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