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.
* Required
Email address
*
Your email
Today's Date
MM
/
DD
/
YYYY
Full Name
Your answer
Email
Your answer
Phone
Your answer
Date of Birth
MM
/
DD
/
YYYY
Height
Your answer
Weight
Your answer
What are your goals and expectations in working with me?
Your answer
What is your main health concern or complaints?
Your answer
Have you worked with a professional in the past and if so, how did that go?
Your answer
What level of stress do you feel you are experiencing at this time?
Minimal Levels of Stress
1
2
3
4
5
6
7
8
9
10
Unbearable Levels of Stress
Explain how you express your stress What coping mechanisms do you use for your stress?
Your answer
What do you do for work and do you enjoy it?
Your answer
What do you do as a form of exercise and how often?
Your answer
Please express your sleep quality?
under 6 hrs per night
6-8 hrs per night
8+ hrs per night
Other:
Do you feel rested upon awakening?
Yes
No
Maybe
Do you smoke or anyone in your house hold?
Yes
No
Will your household (people and environment) support your healthy changes?
Yes
No
Maybe
Other:
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