FM Wellness Lifestyle Intake Form

Lifestyle Assessment Intake Form

Complete the questions .
Name*

First NameLast Name
Email*
example@example.com
How Old Are You?*
Ex: 45
Born Gender*
The gender you were born with and have had no medical surgeries to correct
What is your Date of Birth?*

MonthDayYear
Your Birthday
How Much Do You Currently Weigh?*
Ex: 150lbs
How Tall Are You?*
Ex: 5'7
What are your wellness goals?*
Ex: Feel healthy, lose body fat, increase strength.
How were you referred to me?*

Existing or former clientPhysician or wellness professionalInternet searchSocial mediaOther
Do You Have Any Medical Conditions?*

YesNo
If YES to the above question, please explain:
Ex: What is your condition? high blood pressure, celiac etc. What medications do you take? Losartan 10mg, etc.
Check any of the following you have currently or in the past:*

Kidney DiseaseDecreased Kidney FunctionHistory of Kidney StonesOne KidneyKidney FailureDialysisGall bladder removalGastric Bypass/Gastric SurgeryGut health issues/Colon Resection/OstomyThyroid (Hypo, Hyper, Hyperpara)NONE OF THESE
If you checked any of the boxes above, please elaborate below:
Ex: year of event, year of a surgery, complications, any devices placed inside you, etc.
Are you on any hormone replacement therapies such as birth control, testosterone or illegal steroids?*

yes currentlynoin the past
If you answers YES or IN THE PAST, please explain:
Ex: I am currently taking testosterone injections once per week, in the past i've taken testosterone, i use testosterone pellets, i am on LoEstrin birth control, etc.
If you're a female, are you/have you:

Currently having regular periodspre-menopausalpost-menopausalHad a partial or full hysterectomyTrying to conceiveExperiencing irregular periods and PMS symptoms
Are you currently working with a medical professional such as a physician, nurse practitioner etc. for an on-going or specific condition ?*

yesno
Would you like me to communicate with your medical team regarding your progress or well-being?*

yesnomaybe
If you would like me to communicate with your medical professional please provide their name and contact info:
Ex: Jane Doe, 555-123-4567, jane@doemail.com
How Many meals are you eating per day?*
Ex: 3 meals per day
How Many Snacks are you eating per day?*
Ex: 1 snack after lunch.
Tell me what you eat through the course of a normal day:
Ex: Breakfast is two large eggs, 2 pieces of bacon and black coffee.
Do you take a lunch break?*

yesnosometimes
Do you prepare meals and snacks for yourself to bring to work?*

yesnosometimesOther
If you answered YES or SOMETIMES, please explain:
Ex: I bring my lunch and 1 snack every day.
Please select all cooking appliances you have:*

Oven/stoveMicrowaveInstant pot/pressure cookerAir fryerBlenderFood processor
How many days per week do you purchase "Drive through" food or drinks?*

0 days1-3 days4-5 days6 or more days
If you purchase 'drive through food' regularly, please tell me your go to items:
Ex: Starbucks grande latte, Dunkin donuts wake up wrap, Mcmuffin, Chik Fil A combo, etc.
Do you currently avoid certain foods because you think they cause weight gain?*

yesnosometimes
If you answered YES or SOMETIMES, please explain:
Ex: I avoid bread because I gain weight the next day.
Are you currently tracking your calories using an app such as My Fitness Pal?*

YesNo
If YES, how many calories are you eating per day?*
Ex: 1,500
Are you currently tracking your macros in an app? (Protein, Fat and Carb in grams)*

YesNo
If YES, please tell me the breakdown if each in GRAMS or Percentages:
Ex: Protein 40% or Protein 140g
Are You Interested In Learning How To Use a Tracking App To Balance Your Meals?*

YesNoMaybeAlready Know How
Are you currently following a specific diet? If YES, please explain.
EX: Keto, Whole 30, Mediterranean, Vegan, Vegetarian, Intermittent Fasting etc.
Do you have any food allergies or sensitivities?*

yesnoOther
If you answered YES or OTHER, please explain:
Ex: I'm allergic to dairy and i'm gluten sensitive.
Do certain foods make you feel sick, tired, or bloated?*

yesnosometimesI have no idea
If you answered YES or SOMETIMES, what foods cause issues for you?
Ex: chicken makes me feel bloated and tired, milk gives me a headache, coffee makes me nauseous.
Are there any foods you WON'T eat or DON'T like?*
Ex: I don't like broccoli and I won't eat red meat.
List the foods that you ARE NOT willing to try:*
Ex: I don't like broccoli and I won't eat red meat.
List the foods that you ARE WILLING to try:*
Ex: I like broccoli and red meat.
Do you use protein powder supplements?*

yesnosometimes
If you answered YES, please list the supplement name here (or a link from amazon):
Ex: Sunwarrior Vegan Chocolate Protein Powder
If you consume OVER THE COUNTER supplements, list them here:
Ex: Creatine, Pre-Workout, Fat burner pills, Vitamin D, Multi-vitamin, herbs etc.
How much coffee or caffeinated beverages do you consume per day?*

0 cups1-2 cups3-4 cupsmore than 4 cups
Do you consume coffee/caffeine before drinking water or eating breakfast in the morning?*

YesNoSometimes
Do you experience a mid-afternoon energy crash and use caffeine to "perk" you up?*

YesNoSometimes
Do you add cream, sugar, or sugar substitute to your coffee?*

yes, every time I drink ityes, only once or twice per dayNoOther
If you chose OTHER, explain:
Are you currently exercising? If YES, please explain.*
Ex: Walking 45 minutes 5 days per week, Crossfit 5 days per week, etc.
What time of day do you usually work out?*
Ex: 6am, 5pm, it varies on the day.
Do you work out in a fasted state? (No food)*

yesnosometimes
How long do you wait to replenish your nutrients after you exercise?*

i eat immediately (within 5-10 minutes)i eat within 30 minutesI eat within an hourI eat hours after (2-6 hours after)
Do you use exercises to "off-set" the food you eat?*

yesnosometimes
If you answered YES or SOMETIMES, explain the exercise and your feelings:
Ex: When I eat a dessert item i feel guilty and go for a 20 minute run.
Do you struggle with mindset, motivation and staying accountable?*

YesNoSometimes
Do you struggle with schedule setting, routine and structure?*

yessometimesno
If YES or SOMETIMES, explain:
Ex: I need assistance creating daily routine and structure.
Do you struggle with emotional/stress related eating?*

yesnosometimesin the past
If you answered YES, Sometimes or In The Past, please explain:
Ex: I binge eat when I'm angry, etc.
Do you currently or have you in the past struggled with (check all that apply):*

Binge eatingDrinkingFood RestrictionOver ExercisingFood AversionBody DysmorphiaNone of these
If you selected any item above, please explain:
Ex: 3 years ago I would binge eat until i threw up.
How Would You Rate Your Current Stress Level?*
Ex: 0 being lowest, 10 being highest.
If you rated your stress at a 5 or above, please explain your stress:
Ex: Work related, relationship related, anxiety, depression etc.
What is your favorite way to manage your stress and decompress?*
Ex: go to the beach, go for a walk, read a book, sit in the dark, sleep, listen to music.
Have you sought or are you currently in therapeutic counseling for health related issues such as eating disorders, substance abuse or self-esteem?*

yes previouslyyes currentlynot currentlynot ever
If you are currently in counseling, would you like me to communicate with your professional regarding your progress and well-being?*

yesno
If you answered YES to allowing communication with your professional, please provide their full name, phone number and e-mail address below:
Ex: Jane Doe, 555-123-4567 jane@doemail.com
Are you interested in learning more about Reiki healing to create a deeper connection with your body and manage your stress levels?

yesnoNot sure
Do You get at least 6 hours of uninterrupted sleep per night?*

yesnosometimes
If you answered NO or SOMETIMES, please explain:
Ex: I go to the bathroom multiple times, I wake at certain hours, etc.
Is there anything specific you'd like to ask me or let me know pertaining to your health and wellness goals? If YES, please explain.
I understand that by providing my answers on this form this information will remain confidential and unshared by Fitmind Wellness Solutions and Heather Wright unless authorized by me, and used only for purposes of building a client/provider relationship.

However, any information transmitted or saved via e-mail transmission is not secure and considered public record and Fitmind Wellness Solutions/Heather Wright will not be held responsible for any information obtained via this method.

I understand that all information I have provided on this form is true and correct as it pertains to my personal well-being.

I understand that by authorizing communications with the professionals or individuals listed on this form, my signature provides authorization for Fitmind Wellness Solutions/Heather Wright to communicate with these individuals as it pertains to my health, well-being, care etc. if a professional relationship is established and an agreement is signed between myself and Fitmind Wellness Solutions/Heather Wright.
Your Signature here:*

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Printed Name*

First NameLast Name
Date signed*

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Lifestyle Assessment Intake Form