New Client Intake Form
Email address *
What's your name? *
Your answer
How old are you? *
Your answer
M/F? *
How would you describe your present state of health? *
What else would you like me to know about you? *
Your answer
Please check all conditions and symptoms that apply to you: *
Required
Are you currently taking any prescription medications? *
Your answer
How would you describe your current diet? Tell me about what you eat on a day-to-day basis. Include what you eat on the weekends. *
Your answer
How often do you eat out each week on average? *
Do you experience any barriers when it comes to eating healthier? If so, what are they? Check all that apply. *
Required
Have you ever followed a modified diet? If so, describe. *
Your answer
Are you currently following a specialized diet? *
Required
What do you consider to be the major issues in your diet and eating habits? (ex: eating late at night, lots of snacking, skipping meals, lack of variety, bad cravings) *
Your answer
About how many glasses of water do you drink a day? *
Your answer
Do you have any food allergies or intolerances? *
Your answer
Who prepares your food? *
Do you crave any foods? If so, please specify or give me an example of a craving you experience. *
Your answer
Do you drink alcohol, and if so how many beverages do you enjoy a week on average? *
If you do drink alcohol is it during the weekdays, or weekends or both? *
Do you drink caffeinated beverages? How many per day? *
Do you currently take any vitamin, mineral or herbal supplements? If so, which ones? *
Your answer
Do you consider yourself to be fit or in good physical shape? *
Do you exercise regularly and if so, how often? *
What types of exercise do you participate in? *
Required
Have you experienced any injuries that may limit your physical activity? If so, please describe. *
Your answer
What would you like to do with your body composition? *
What is your present weight? *
Your answer
What is your current body fat percentage? If you don't know, answer "NA". *
Your answer
Rank your goals for working with a health coach. What is important to you? *
Not at all important
Somewhat important
Extremely important
Improve body composition (lose body fat/build lean muscle)
Improve eating habits
Improve mood and ability to cope with stress
Increase energy level
Feel better overall
Be happier/increase confidence
Establish lasting lifestyle change
In your own words, tell me what you're hoping to accomplish while working with a health coach. *
Your answer
On a scale of 1-10, how ready are you to adopt a healthier lifestyle? *
I'm not sure...
I'm so ready!
Are you prepared to experience even greater life changes after transforming your health? *
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