CEN Client Intake Form
Full Name
Phone Number
Email Address
Gender
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Age
Height/Weight
Why are you seeking out the help of a Nutritionist?
Are you currently taking any medications/supplements?
Do you have any known allergies/food intolerance's?
How would you describe your health?
What are your main health concerns?
What aggravates your health concern?
Do you/have you smoked tobacco?
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Do you drink alcohol? If so, how often and how much?
What is your occupation?
On a scale of 1-10 how stressful is your job?
Not at all
I want to quit
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How many times a week do you exercise and for how long?
Please describe your current exercise routine.
How many hours of sleep do you get on average?
How many times during the night do you wake up?
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Please select the answer that fits you best. I am a....
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Do you experience a dip in energy mid-afternoon?
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Please describe an average day of eating. (Breakfast, Lunch, Dinner and Snacks)
When you feel the munchies coming on what do you crave?
How many glasses of water do you drink a day?
How many cups of coffee do you drink a day?
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Please select all that apply. After eating I feel.....
Have you ever completed an elimination diet? If so, what did you eliminate?
Please list all diets you have tried. (ie. WW, Paleo, Atkins, Keto etc...)
How often do you have a bowel movement?
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Please select all that apply. My bowel movements are often....
Do you suffer from any of the following. Please select all that apply.
The following four questions are for women only. Are you peri-menopausal or menopausal?
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Do you have regular periods? If not, please elaborate.
During your period do you experience any of the following?
Are you currently taking a hormonal form of birth control. If so which brand?
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