Intake Form
This form is our intake questionnaire. Please request a food journal at hello@aviditysisters.com if you haven't been sent one already.

Please submit payment after completing the form as well.

Thank you!

Email address *
Avidity Sisters *
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Please enter your information
Full Name (First Name, Middle Initial, Last Name) *
Date of Birth *
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DD
/
YYYY
Gender
Marital Status
Address
Mobile Phone *
Home Phone
Work Phone
E-mail *
Preferred contact method
Weight and Height Information
Your Height
Current Weight
Desired Weight
Is your weight stable or up and down?
Were you referred to us by anyone (physician, friend, etc.)? If Yes, who? If No, how did you hear about us?
Have you ever consulted a professional (Holistic Nutritionist/ Dietician) about your nutrition? If Yes, when was that? Please describe what concerns you had in mind then and how effective the consultation was.
Please list your top major health concerns in order of importance, and indicate date of diagnosis (where relevant):
Please list 1 to 3 health goals you would like to attain for yourself, in order of priority:
What habits, activities or attitudes do you consider to have contributed to any if your problems or reasons you feel your goals haven't been met?
Please list any prescribed medications you take. (Name, Dosage, How long?)
Supplements now or in the recent past. (Name of supplement, Dosage, Duration, Benefits, Side effects)
Any allergies to medications? If Yes, please specify below. (Name of the drug, Type of reaction)
Other allergies or sensitivities (Foods, Pollen, Animals, Chemicals)
Nutrition and Dietary Habits
How many meals do you typically eat per day?
How many times a week do you eat breakfast?
How many times a week do you eat out at resturants?
Do you normally eat alone or with friends/family?
What is your weekly budget?
List your favorite 3 meals
Do you snack?
How many times a week do you cook meals at home?
How many times a week do you grocery shop?
Where do you grocery shop?
Do you read food labels?
List your favorite restaurants and the type of food they serve:
Eating Patterns
Check all that apply:
Do you consume the following? Write "Yes" for those applicable and include frequency:
Artificial sweeteners
Soy products
MSG
Dairy
Eggs
Nuts / seeds
Alcohol
Fast foods
Sweets / desserts
Fried foods
Coffee / black tea
Soda / diet soda
Fruit juice or fruit drinks
Bread / pasta (refined)
Whole grains
Red meat
Poultry
Pork
Seafood
Beans
Legumes
Vegetables
Whole fruits
Water
Other(s), please specify
What 3 foods could you never give up?
What 3 foods do you refuse to eat?
Do you follow a specific diet?
Have you tried any popular diets? If yes, which ones and for how long?
If applicable, how were your experiences with popular diets?
What influences your food choices? Check all that apply:
How much water do you drink per day?
Your Activity Level
Do you exercise regularly?
How often?
Type of exercise:
Length of sessions:
Do you sweat?
What level of stress do you consider yourself to be under?
Health history - Circulatory and respiratory (check all that apply)
Health history - Skin (check all that apply)
Health history - Digestive (check all that apply)
Health history - Other (check all that apply)
To women only*
Perimenopausal?
Regular periods?
Pregnant? If Yes, how many weeks?
Do you suffer from PMS? If Yes, please describe it.
Menopausal?
Irregular periods?
Feel free to use the space below to inform me with any extra information pertinent to your health:
Please attach anything you feel would help us help you better - food journal, blood work, test results, etc.
All of the information provided is true and I allow Avidity Wellness Consulting & Events to access it in order to provide further assistance. *
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