HealthCreators Whole30 intake form
Please provide as much detail as possible to allow for the best initial consult.
Height (in meters)
Weight (in kilograms, estimation is fine)
How familiar are you with Whole30?
Have you done a Whole30 before?
Yes, and skipped reintroduction
Yes, and didn't complete it
Yes, should have restarted but kept going anyway
Which, if any, of the Whole30 books have you read?
It starts with food
Food Freedom Forever
Whole30 Day by Day
Read a lot on Whole30.com
What do you desire to achieve through the Whole30?
Improve relationship with food
Get more energy
Increase understanding related to food allergies and my personal sensitivities
Improve my physical health
Improve my emotional health
Improve mine (and my family's) nutritional status
Decrease body fat
Improve my PR (Sports related)
Nothing, I have no goals…
Do you have a history of (yoyo) dieting? Example: periods of Weight Watchers, SlimFast (or something like it), following trendy diets, switching between very restrictive/exercising lots & beings inactive/eating whatever
Any recent significant weight changes over the past year? 10% or more? Ex: gastric bypass, lengthy illness, strict dieting
Have you ever been in treatment for an eating disorder?
Biggest barrier to healthy living?
Family support, or lack of
Too far gone, too set in ways
Lack of planning
Lack of understanding
Can't pass the office cookie jar or deny a weekend drink
Do you cook or prepare meals? How often?
Do you smoke?
Do you consume alcohol? (type and frequency)
Do you consume caffeine? (type and frequency). Example: black coffee, every morning. 2 diet cokes throughout day.
Food allergies or intolerances? (Or, suspected)
Exercise regime and schedule? Example: 1 hour of cardio 3 days a week (run, zumba, bike) + 2 days of training at CrossFit
Sleeping Habits or problems?
Supplements you currently take:
Omega 3 / Fish oil
Pertinent medical history. Example: Hypertension, (pre)diabetes, heart attack, obesity, IBS, PCOS, cirrhosis
Abnormal recent lab values. Example: blood sugar, HgbA1C, triglycerides, LDL, HDL, cholesterol
Do you use (prescribed) medication? What and what for?
What coaching services are you interested in? Check all that apply.
Information on how to do a Whole30
Information during the Whole30
Focus on the other aspects of Whole30 (besides: What shall I eat)
Help with habit change
Accountability (text, calls, emails)
Meal planning / recipe guidence
Reintroduction, process & accountability (post Whole30)
Reintroduction, interpretation and possible solutions (Post Whole30)
Food Freedom (post Whole30)
How were you referred?
Whole30 HealthCoaching by HealthCreators services are intended to promote general health and wellness and are not intended to replace physician care or medical intervention. All nutritional assessments, suggestions and/or consultations on nutrition, diet and lifestyle are based on your input, and are not intended to diagnose, treat or cure any disease or ailment.You acknowledge and agree to accept all responsibility for reviewing diet, nutrition, and lifestyle suggestions with a licensed medical professional before following said suggestions. As with any program, there may exist inherent risks which may be relative to your state of health, fitness, awareness, care, and skill to which you conduct yourself. You agree that it is your responsibility to inquire about any recommendations with which you are not familiar and provide any information which may limit your participation in the Whole30 program. Results and changes in your general health and wellness may vary depending on medical conditions, medications, and accuracy in following suggested guidelines. As your general health and wellness may change with modifications in diet, nutrition, and lifestyle, physician-prescribed medications may require modification. It is your responsibility to discuss this with your physician. Never reduce or eliminate physician prescribed medications without the direction of your physician or medical care provider. Your personal and health information will remain confidential and will not be shared without your consent. Brenda & Naomi of HealthCreators reserve the right to refuse services to any individual. Acknowledgement & Consent to Receive Services: I have read and understand the above disclosure about the Whole30 coaching services offered by HealthCreators. I have discussed with HealthCreators the nature of the services to be provided. I understand that Naomi & Brenda are not licensed physicians and that Whole30 coaching services are not licensed by the state, medically authorized, nor sponsored by any licensing bodies. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor or licensed health provider. I have consented to use the services offered by HeathCreators and agree to be personally responsible for the fees in connection with the services provided to me. By signing below, you agree to the above terms and conditions for participation in Whole30 coaching with HealthCreators:
I have read and agree with the above statement
I do not agree and need to discuss further
Send me a copy of my responses.
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