Accutane Recovery Intake Form

John Nicoll

Hello! If you’ve been impacted by accutane, I deeply sympathize and honor your desire to recover your health. Please fill out this intake form with the following considerations in mind:

  • For any answers longer than one word, please type your answer in a separate document and then copy them into this form. (This is more easily done if you use a laptop or desktop computer.) This is so that if something goes wrong with the form submission, you won’t lose your answers.
  • Please be as detailed as possible in your answers.
  • If you don’t feel comfortable answering a particular question, that’s ok. Just type “prefer not to answer.”
  • Note that any behavior(s) that you may feel embarrassed about likely has to do with neurotransmitters. Knowing about your behaviors can help us identify which neurotransmitters you may be deficient in. While dealing with accutane damage, I suffered from severe, suicidal depression and compulsive behaviors as my system tried desperately to regulate itself.
  • After you complete this form, you will be asked to sign a client information letter, client agreement, and consent for treatment form. All these are necessary before I can work with you.

Estimated time to complete: 30 mins

    I am filling out this form for:

    Accutane History

    Have you ever taken any of the following medications: Accutane, Isotretinoin, RoAccutane, Claravis, Sotret, Myorisan, Amnesteem, Absorica?
    At what age did you take the drug?

    Is accutane damage causing specific problems in your life?

    Medication History

    Have you taken any prescription medications in the past that you are no longer taking? (There is a place later in the form to list any medication you are currently taking.)

    Having any of these medications and a lasting impact on you? (Positive or Negative)

    Relaxation & Sleep

    How is the quality of your sleep?
    Do you wake up in the night?
    If so, what time(s)?
    Do you go back to sleep easily or stay awake?
    When do you wake up in the morning? What time do you get out of bed?
    What time do you go to bed?

    Do you have difficulty relaxing? If yes, describe.

    Are you experiencing anhedonia (the inability to feel pleasure)?

    Exercise

    How much do you exercise? What kinds?

    Food & Digestion

    Are you currently on a low carb diet (<50g of carbohydrates per day)?

    What do you eat? Give an example of what you eat on (1) a day when you feel that you're eating well and (2) a day when feel you're not.

    Do you have any struggles with food? How about digestion?

    Do your stools indicate to you that there is a problem with your digestion? (Ok if you don't know)

    Do you feel that your current approach to food is working for you? If not, what's not working?

    Do you feel your weight is:

    Mental & Emotional

    Is there anything you'd like to share about mind and/or emotions? Depression and suicidal thoughts are known accutane side effects. Share anything you feel is important.

    Physical Energy

    How is your physical energy throughout the day?

    Libido

    Accutane is known to cause loss of libido and in some cases, loss of sensation in the genitals. Have you experienced either of these effects?

    Support

    Are you seeing any other health practitioners? (therapists, doctors, nutritionists, healers, acupuncturists, etc..)

    If yes, please list them along with what they are helping you with and their contact info (website and phone or email):

    Are you currently taking any medications? If yes, please list them along with the reason for each and who prescribed them:

    Please list any supplements you are currently taking and why you are taking each one:

    Have you recently had any blood work done? Were any of the results abnormal? (i.e., something too high or too low)

    Have you had any genetic testing done? If yes, have you discovered any "abnormal" genes? (i.e., MTHFR gene)

    High Sensitivity

    Do you identify as highly sensitive?
    Am I highly sensitive? > (opens in a new window)
    Is my child highly sensitive? > (opens in a new window)

    Behaviors

    This form is confidential.

    Social media / phone usage

    How many hours per day? Do you spend time on your phone after 8pm?

    Recreational Drugs

    Do you use any recreational drugs?

    Alcohol

    Please describe your alcohol use.

    Smoking

    Do you smoke cigarettes, e-cigarettes, or marijuana?

    Compulsions/Addiction

    Share as much or as little as you feel comfortable.

    Other

    Is there anything else you'd like me to know?



    Disclaimer: By visiting this website, scheduling a consultation or appointment, and or booking a session with John Nicoll, you understand and agree that John Nicoll is a practitioner of Brennan Healing Science, Intuitive Healer, Health Researcher & Consultant, and Keto Consultant, but not a Physician, Nutritionist, Psychotherapist, or other licensed professional. His advice, coaching, consultations, healing sessions, and courses are offered to supplement Western and Traditional medical protocols. Please consult your physician or other licensed health care professional for any physical or psychological conditions you may be experiencing.



    IMPORTANT: As a precaution please take a moment to copy and paste all your answers into a separate document before you press submit!