Email

Height

Weight (you can choose to skip this)

current weight, weight 6 months ago, weight 1 year ago, Is/has weight been a concern?

Social info

Where do you live? Tell me about your living environment (ex: life with boyfriend, have a dog)

What do you do for work and what's your work sched like? How's your stress (scale 1-10) re: work?

Health History

How is the health of your parents? How about the health of your household growing up?

How was your diet growing up? Any defining details..

Provide examples of breakfast, lunch, dinner, snacks, etc. Ex: Always ate a second lunch after school because of sports

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's your exercise routine like? How does it ebb and flow?

How's your sleep? How many hours on avg. do you sleep?

How is your digestion? Do you experience gas, bloating, constipation, etc.?

What medications / supplements do you take?

Have you had any injuries, surgeries or other major health experiences?

Women's Health

Tell me about your period? Frequency, symptoms, etc.

Feel free to add details on any other women's health related concerns (ex: chronic yeast infections)

Diet History

Tell me about your day-to-day eating habit. Do you cook? What are some go-to meals?

Do you have any regular cravings? Relationship with alc, drug use?

Coaching

What are your health goals and what are you looking to get out of working together? Be specific!

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?

Intake Form