HealthCreators Whole30 intake form
Please provide as much detail as possible to allow for the best initial consult.
Email address *
Name *
Your answer
Height (in meters)
Your answer
Weight (in kilograms, estimation is fine)
Your answer
How familiar are you with Whole30?
Unfamiliar
Very familiar
Have you done a Whole30 before?
Which, if any, of the Whole30 books have you read?
What do you desire to achieve through the Whole30?
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
Your answer
Any recent significant weight changes over the past year? 10% or more? Ex: gastric bypass, lengthy illness, strict dieting
Your answer
Have you ever been in treatment for an eating disorder? *
Required
Biggest barrier to healthy living?
Do you cook or prepare meals? How often?
Your answer
Do you smoke?
Do you consume alcohol? (type and frequency)
Your answer
Do you consume caffeine? (type and frequency). Example: black coffee, every morning. 2 diet cokes throughout day.
Your answer
Food allergies or intolerances? (Or, suspected)
Your answer
Exercise regime and schedule? Example: 1 hour of cardio 3 days a week (run, zumba, bike) + 2 days of training at CrossFit
Your answer
Sleeping Habits or problems?
Your answer
Supplements you currently take:
Pertinent medical history. Example: Hypertension, (pre)diabetes, heart attack, obesity, IBS, PCOS, cirrhosis
Your answer
Abnormal recent lab values. Example: blood sugar, HgbA1C, triglycerides, LDL, HDL, cholesterol
Your answer
Do you use (prescribed) medication? What and what for?
Your answer
What coaching services are you interested in? Check all that apply.
How were you referred?
Your answer
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: *
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