Nutrition and Wellness Intake Form
It is important to thoughtfully answer as many questions as you can so that I might get a holistic view of your health status at present, what your goals are, any barriers I might help you remove, and your vision for your health in the future.
Email address *
Today's Date
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Full Name
Email
Phone
Date of Birth
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Height
Weight
What are your goals and expectations in working with me?
What is your main health concern or complaints?
Have you worked with a professional in the past and if so, how did that go?
What level of stress do you feel you are experiencing at this time?
Minimal Levels of Stress
Unbearable Levels of Stress
Clear selection
Explain how you express your stress What coping mechanisms do you use for your stress?
What do you do for work and do you enjoy it?
What do you do as a form of exercise and how often?
Please express your sleep quality?
Clear selection
Do you feel rested upon awakening?
Clear selection
Do you smoke or anyone in your house hold?
Clear selection
Will your household (people and environment) support your healthy changes?
Clear selection
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