Intake FormPlease complete the form below to give me more insight into your health history and goals so that I can best tailor our consultation. Name * First Name Last Name Email * Phone * (###) ### #### Birthdate * MM DD YYYY Height * Weight current weight, weight 6 months ago, weight 1 year ago, Is/has weight been a concern? Social Information Relationship status * Where do you live? Who do you live with? * Do you have any pets? Other big commitments? * What is your occupation and what is your general work schedule? * Health History How is/was the health of your mother? * How is/was the health of your father? * How was your diet as a child? * Provide examples of breakfast, lunch, dinner, snacks, etc. How would you describe the health of your household growing up? * At what point in your life have you felt your healthiest? * Have you worked with any doctors or healers historically? * How was that experience? General Health What is your relationship with exercise? * How is your sleep? How many hours do you sleep each night? * How is your digestion? Do you experience gas, bloating, constipation, etc.? * Do you experience any pain or stiffness? * Allergies or food sensitivities? * What medications / supplements do you take? * Have you had any injuries, surgeries or other major health experiences? * Women's Health Do you get your period? If so, how many days and how frequent is your cycle? Period symptoms? History with birth control? Do you experience yeast infections or UTIs? Any other discomforts? Diet History What is your diet like now? * Do you cook? How often? * Where does the rest of your food come from? How do you prioritize what to eat? * Do you or have you experienced strong cravings? i.e. sugar * Do you drink alcohol or use recreational drugs? * Have you struggled with an eating disorder? Please provide details. * Coaching What are your health goals? * What are you looking to get out of this program? * Will your family and friends be supportive of your desire to make food and/or lifestyle changes? * What is the most important thing you think you should change about your lifestyle to improve your health? * Anything else you'd like to share? Health Outlook * I am satisfied with my overall health. Strongly Disagree Disagree Neutral Agree Strongly Agree I eat a healthy, well balanced diet. Strongly Disagree Disagree Neutral Agree Strongly Agree I prioritize regular exercise and daily movement. Strongly Disagree Disagree Neutral Agree Strongly Agree I believe I am in control of my physical wellbeing. Strongly Disagree Disagree Neutral Agree Strongly Agree How did you hear about me? * Friend Instagram Google Other Thank you! I’ll be in touch shortly to confirm your consultation.
