CEN Client Intake Form
Full Name
Your answer
Phone Number
Your answer
Email Address
Your answer
Gender
Female
Male
Other
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Age
Your answer
Height/Weight
Your answer
Why are you seeking out the help of a Nutritionist?
Your answer
Are you currently taking any medications/supplements?
Your answer
Do you have any known allergies/food intolerance's?
Your answer
How would you describe your health?
Your answer
What are your main health concerns?
Your answer
What aggravates your health concern?
Your answer
Do you/have you smoked tobacco?
Yes
No
Other:
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Do you drink alcohol? If so, how often and how much?
Your answer
What is your occupation?
Your answer
On a scale of 1-10 how stressful is your job?
Not at all
1
2
3
4
5
6
7
8
9
10
I want to quit
Clear selection
How many times a week do you exercise and for how long?
Your answer
Please describe your current exercise routine.
Your answer
How many hours of sleep do you get on average?
Your answer
How many times during the night do you wake up?
0
1-2
3+
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Please select the answer that fits you best. I am a....
Night Owl
Morning Person
Neither, I'm tired all the time
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Do you experience a dip in energy mid-afternoon?
Yes
No
Sometimes
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Please describe an average day of eating. (Breakfast, Lunch, Dinner and Snacks)
Your answer
When you feel the munchies coming on what do you crave?
Your answer
How many glasses of water do you drink a day?
Your answer
How many cups of coffee do you drink a day?
0
1-2
3-5
6+
Clear selection
Please select all that apply. After eating I feel.....
Satisfied
Bloated
Sleep
Hungry
Energized
Have you ever completed an elimination diet? If so, what did you eliminate?
Sugar
Dairy
Gluten
High Fodmap
Soy
Other:
Please list all diets you have tried. (ie. WW, Paleo, Atkins, Keto etc...)
Your answer
How often do you have a bowel movement?
Once a day
Once every two days
Once every three days
I'm not sure
Clear selection
Please select all that apply. My bowel movements are often....
Hard and small
Loose and watery
Soft and well formed
I'm not sure
Do you suffer from any of the following. Please select all that apply.
Constipation
Diarreha
Bloating
Gas
Cramping
Heart Burn
Nausea
The following four questions are for women only. Are you peri-menopausal or menopausal?
Peri-menopausal
Menopausal
Clear selection
Do you have regular periods? If not, please elaborate.
Your answer
During your period do you experience any of the following?
Cramping
Clotting
Heavy Bleeding
Fatigue
Water Retention
Other:
Are you currently taking a hormonal form of birth control. If so which brand?
Your answer
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