This form is our intake questionnaire. Please request a food journal at
if you haven't been sent one already.
Please submit payment after completing the form as well.
I agree to the terms and conditions stated herein.
Please enter your information
Full Name (First Name, Middle Initial, Last Name)
Date of Birth
Preferred contact method
Weight and Height Information
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:
Check all that apply:
Eat too much
Eat too little
Forget to eat
Eat out of boredom
Hungry all the time
Late night snacking
Eat in the car
No joying in eating
Other (Please specify)
Do you consume the following? Write "Yes" for those applicable and include frequency:
Nuts / seeds
Sweets / desserts
Coffee / black tea
Soda / diet soda
Fruit juice or fruit drinks
Bread / pasta (refined)
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?
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)
Cold feet or hands
High blood pressure
Shortness of breath
Low blood pressure
Health history - Skin (check all that apply)
Health history - Digestive (check all that apply)
Health history - Other (check all that apply)
Loss of appetite
To women only*
Pregnant? If Yes, how many weeks?
Do you suffer from PMS? If Yes, please describe it.
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.
Yes (By clicking "Yes", I certify that the above information are true and correct and I allow Avidity Wellness Consulting & Events to access it in order to provide further assistance.)
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