Kim Danger - Holistic Nutrition CLIENT INTAKE FORM
Hi, I'm Kim! I'm a certified fitness instructor, holistic nutritionist and Reiki practitioner. This form will help me get to you know you so I can best help you with your health goals. Please tell me about your current struggles, goals, and motivation to change.
Email address *
Your Full Name *
Your answer
Your Age
Your answer
What is your long-term health and nutrition goal? *
Your answer
If weight loss is your goal, how much would you like to lose long-term?
How often, on average, do you eat processed foods? *
Which topics/conditions CURRENTLY apply to you?
Tell me about your immediate family history (parents, grandparents, siblings) and any genetic health conditions they may have had that you are concerned about (cancer, heart disease, diabetes, high blood pressure, etc.). *
Your answer
Think back to the last week. On average, how many servings of vegetables did you get per day? (Do not include starchy vegetables like potatoes and corn) *
Think back to the last week. On average, how many servings of fruit did you get per day? *
Think back to the last week. On average, how many glasses of water (8-oz) did you drink each day? Please do not count other water-containing beverages like tea, coffee, etc. *
Tell me about your limitations - motivation level, time, family situation, etc. What are the main obstacles holding you back from achieving your goals? *
Your answer
What is motivating you to make a change now, and what do you hope to get out of this consultation? *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.