Client intake form

Client Intake Form
Purpose

All information received on this form will be treated as strictly confidential. Please fill out the form completely and accurately. This information is essential to helping the nutritionist to develop a wellness program that addresses your needs, goals and interests and is safe and effective. Information provided here will allow me to determine if I am able to take you on as a client and furthermore if any more medical clearance is required before we can work together. Sections marked with an Asterix * are required and your form cannot be submitted without an answer.
Personal Information
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender*

FemaleMale
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Why have you made an appointment to see me?*
Medical History
Please indicate whether you have been diagnosed with any of the following diseases or symptoms

AnemiaAnxiety or Panic AttackArthritis (osteoarthritis or rheumatoid)AsthmaBronchitisCancerChronic Fatigue SyndromeDiabetes: Type IDiabetes: Type IIPrediabetesDepressionDiagnosed food allergy/intoleranceEating disorderEczemaEpilepsyGestational DiabetesGoutGastrointestinal surgeryFibromyalgiaFungal InfectionHeart AttackHeart disease, myocardial infarction (heart attack), atrial fibrillation, bypass graft or valve replacementHepatitisHigh blood fats (cholesterol)High blood pressure (hypertension)Hypoglycemia (low blood sugar)Kidney disease/reduced renal functionHeadache/migraineInfertilityMusculoskeletal/painIBSHave you been diagnosed with PCOS or endometriosis?Other
Provide further information if any
Do you take any prescribed medication? If yes, list below name, dosage and frequency
Do you take any vitamins or supplements? If yes, list below name, dosage and frequency
Nutrition & Health
How often do you skip meals?*

DailyOccasionally (a few times a week)Rarely (a few times a month)Never
Do you have any food allergies or intolerances? If yes, list below
Which best describes your bowel habits*
How many hours sleep do you average per night?*
Do you smoke tobacco products?*
Do you drink more than 10 standard drinks per week?*
List any food preferences likes/dislikes
Do you have a history of yo-yo dieting?*
If yes, please provide more details
Is your occupation sedentary?*
What is your occupation?
What diets have you tried in the past? Were they successful or not?
Have you ever tracked your calories or macros before?*

YesNo

Rate your current nutrition knowledge*

	1	2	3	4	5

1 is Worst, 5 is Best

How would you rate your stress levels*
Which of these most aptly represents your approach to food*
Do you have at least 3 serves of vegetables and 1 serve of fruit per day?*
How would you rate your ability to adapt to change?*
Do you suffer from, or have you been diagnosed with an eating disorder (anorexia, bulimia, purging, night eating syndrome, other?*
How would you rate your ability to focus?*
How would you rate your current libido?*
Have you had any unexplained loss of muscle or body fat gain?*
Rate your readiness to change*
How much support do you feel you need to achieve your goals?*
Which of these do you struggle with?*

AccountabilityKnowledge of nutritionExercise programmingMeal prep/planningKnowing if you are doing what is right to reach your goalTime managementMindsetBody imageConsistency and adherence to nutrition/trainingOther
What else (if not listed above) is holding you back (barriers) to reaching your health goals?
Are you ready to commit to following the advice given by EmpowerMe Nutrition & Fitness?****

YesNoI'm not sure
*** The reason I ask you this is because I want to work with clients that are ready to take resonsibility and control of their health. If you aren't quite there yet that's totally okay but I don't want to waste your time and money if you aren't willing to put in the hard yards. We can talk more about this in an initial consult or prior to if you're not sure where you are at.
Why do you wish to work with me specifically as a coach/nutritionist?
Enter your current height and weight so your BMI can be calculated*
Exercise History

Please fill this out with the last 6 months in mind
Do you exercise regularly*
What type of exercise and how frequently?
Rate your experience with exercise*
Rate your ability to perform cardio exercises*
How often do you have time to exercise?*
Please select the physical activities you are involved often

Stretching/YogaCardio/AerobicsStrength-trainingSports or LeisureOther
How would you rate your training performance?
What equipment do you have access to?*

Free weightsGym machinesCable weightsResistance bandsBosu ballsKettlebellsTRX bandsOther
What are your fitness goals?*

AppearanceCardiovascular enduranceFlexibilityHealth (General)Muscular definitionMuscular strength/powerSelf esteem/confidenceSpeedSports performanceStress reductionToning and shapingWeight lossPostureOther
Do you have any existing injuries or conditions that I should be aware of while building your training plan?*
What is your dream weight?
What is your acceptable weight?
Do you have a smart/fitness watch? If so, what type?
E.g. Garmin, FitBit, Apple Watch
How did you find out about EmpowerMe Nutrition & Fitness*
If someone referred you, who was it?
Our Terms and Conditions
One's health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.
Consultation Agreement
I agree to the following conditions for the upcoming consultation with my nutritionist:

- The information I have provided/will provide via questionnaires, phone, email, in-person, or by any other means of communication is accurate to the best of my knowledge.
- The recommendations I will receive from my nutritionist are not a substitute for medical advice from a qualified doctor.
- The advice I will receive from my nutritionist is personal and applies to me only. This same advice may be ineffective or even harmful when applied to other people with different background.
- I must communicate to my nutritionist any changes in my medical prescriptions or treatments for the duration of my nutrition plan.
- I must inform my nutritionist promptly if any of my new changes in diet or lifestyle start to cause me adverse effects.
- I understand that the advice I shall receive will not be enough to achieve my nutrition or lifestyle goals unless I follow it diligently and commit to it fully.
- I understand any changes in my diet and lifestyle may produce effects in my body, energy, health, and condition that are gradual in nature – not instantaneous.
- I understand that, although my nutritionist/dietitian will endeavor to help me achieve my nutrition and lifestyle goals to the extent possible, the possibility exists I may not fully attain my goals due to factors outside the control of my nutritionist.
Date

MonthDayYear
Date
Signature

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Client Intake Form

Purpose

Personal Information

Medical History

Nutrition & Health

Exercise History

Our Terms and Conditions

Consultation Agreement