Intake Form

Your name

Your email

Your Phone Number

Age in Years

Date of Birth

Current Weight (Please mention Lbs or Kgs)

Weight 6 Months Ago

Weight 1 Year Ago

Would you like your weight to be different?
YesNo

Social

Relationship Status

Where do you live?

Any children?

Any pets?

Occupation

How many hours do you work per week?

General Health

What are your main health concerns?

Any other concerns and/or goals?

At what point in your life did you feel your best?

Any current or previous serious illnesses, hospitalizations, or injuries?

How is/was your mother’s health?

How is/was your father’s health?

What is your ancestry?

What is your blood type?

How is your sleep?

How many hours do you sleep per night?

Do you wake up during the night?

If so, why?

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas?

Any allergies or sensitivities?

Medical

List all supplements or medications

Are you involved with any healers, helpers, or therapies?

What role do sports and exercise play in your life?

Food

Will your family and friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where does your non-home-cooked food come from?

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What foods do you typically eat these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?

What is the most important thing you should change about your diet to improve your health?

Is there anything else you would like to share?

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