Intake Form It Is What You Eat
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Are you under the care of a qualified healthcare professional? Please list whom.
It is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and is monitoring medications and any heath concerns that you list here (besides stress and weight issues). If you are on medications (particularly for high blood pressure or hypothyroidism), I will monitor those that may need changed as you lose weight, but you will need others to be monitored during and after the program as your need for them may change.
List any medical diagnoses you have:
What medications, supplements and over the counter items do you take regularly or are currently prescribed:
List past surgeries and hospitalizations
List any allergies to medications
What are your main interests and hobbies?
What is your line of work or study
Are you married or in a relationship?
Do you have people close to you who support you?
Do you exercise regularly? Please detail
What are your barriers to exercise?
What kind of other movement or activities do you enjoy?
Do you have problems falling or staying asleep?
How many hours do you sleep in a night?
Do you wake up refreshed?
How is your energy?
Does your energy level affect your daily activities?
How would you describe your mood, generally?
Does your mood affect your life or daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
How many hours of screen time do you average per day?
Diet and Lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Do you use recreational drugs?
How is your appetite?
How many meals per day do you eat?
What is a typical day, in terms of food intake? Please list all meals, snacks, and beverages
How many fluids do you normally drink? Please approximate in ounces
Please list all types of beverages you regularly drink
Please list any food allergies, intolerances or foods you avoid and the reason
What past struggles and difficulties have you experienced in terms of food and dieting?
Please list the factors you feel have contributed to your current weight:
What diet and exercise programs, protocols, plans or approaches have you tried in the past?
What types of diet and exercise approaches have worked for you in the past?
What hasn't worked for you at all?
Current picture of your health
Not Currently,but within the last year
Not currently and longer than 1 year ago
Unexplained weight loss or gain
Change in appetite
Disordered Eating Pattern/Tendency
Lack of mental focus
Blood sugar irregularities
Excessive thirst or hunger
Abnormal hair growth
Feeling excessively hot or cold
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Cold or pale extremities
Short of breath
Abdominal discomfort after eating
Daily bowel movements
What is your reason for seeking treatment at this time?
What is your weight goal?
What are your sleep goals?
What are your fitness goals?
What are your health goals?
Anything else you'd like me to know?
Should be Empty: