Holistic Nutrition Client Intake Form
Please answer all questions thoroughly and as honestly as possible. This form is confidential and the information provided cannot and will not be given to anyone without your written permission.
Date:
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Month
-
Day
Year
Date
Name:
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First Name
Last Name
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number:
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Format: (000) 000-0000.
E-mail:
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example@example.com
How did you hear about me?
*
Please Select
Referral
Mr. and Ms. Day Spa
Website/Google Search
Yelp
Instagram
Facebook
Other
If Referral, please list name:
Age:
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Gender:
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Marital Status:
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Single
Married
Separated
Divorced
Widowed
Height:
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Weight:
Occupation:
List your major health concerns in order of importance:
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List the date and description of any surgical procedures you have had or plan to have in the future:
Check mark the box if you've had or have blood relatives with any of the following:
Cancer
High Blood Pressure
Diabetes
Heart Disease
High Cholesterol
Thyroid Disorder
N/A
Other
List all prescription medicine(s) you are currently taking:
List all vitamins, minerals, herbs, and nutritional supplements you are currently taking:
How would you describe your general health?
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What would you like to change most about your lifestyle?
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What behaviors, habits or thoughts would you like to eliminate?
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Please list any skin conditions you may have and briefly describe your symptoms (ex: eczema, psoriasis, dermatitis, acne, etc):
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List your favorite foods / meals you like to eat:
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List your least favorite foods / anything you dislike eating (including condiments):
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List any foods you exclude from your diet:
List any foods that you crave:
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom:
Have you ever had or have periods of eating junk food, binge eating or dieting? List any known diet that you have been on for any amount of time:
Please list all known food allergies, sensitivities, intolerances and/or reactions:
Are you currently on a special diet?
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Paleo
Dairy restricted or dairy-free
Vegetarian
Vegan
Blood type
Raw
Refined sugar-free
Keto
Gluten-free
N/A
Other
If other, please explain:
How many meals do you generally eat each day?
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One
Two
Three
Three+
How many snacks do you generally eat each day?
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One
Two
Three
Three+
N/A
What is your favorite meal of the day?
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Breakfast
Lunch
Dinner
Dessert
N/A
Do you:
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Eat out often
Diet frequently
Skip meals frequently
N/A
Other
If other, please explain:
What percentage of your meals are home-cooked? Please describe:
How much water do you drink per day?
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Do you drink more than 4 caffeinated beverages per day? (tea, coffee, soda, energy drinks)
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Yes
No
Do you put cream and/or sugar in your coffee or tea?
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Yes
Sometimes
No
N/A
Which of the following foods do you consume regularly?
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Soda
Diet soda
Refined sugar (white bread/ white rice)
Alcohol
Fast Food
Gluten (wheat, rye, barley)
Dairy (milk, cheese, yogurt)
Coffee
N/A
Other
If other, please explain:
How often do you have a bowel movement?
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1-3 times per day
More than 3 times per day
Not regularly every day
Do you drink alcohol?
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Yes
No
On occasion
If yes, please list:
Do you smoke tobacco?
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Yes
No
If yes, how often do you smoke?
Do you exercise?
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Yes
No
If yes, how many times per week do you exercise?
If yes, rate your current physical activity level:
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Low
Moderate
Heavy
N/A
Do you have trouble falling asleep?
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Yes
Sometimes
No
Do you wake up at night and can't fall back to sleep?
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Yes
Sometimes
No
If yes, what keeps you up?
Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby, and am breastfeeding
N/A
Please rate your stress level
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Low
Medium
High
How do you handle stress?
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At what point in your life did you feel your best? Why?
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How are your moods in general? Do you ever experience any anxiety, depression or anger?
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Is there anything else you'd like me to know about your current diet, history, or relationship with food?
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I am employing the nutrition counseling services of Robin Pettus so that I can obtain information and guidance about health factors within my own control (diet, nutrition, and related behaviors) in order to support a healthy lifestyle.
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Yes, I am employing Robin Pettus as my nutrition counselor
I understand that Robin Pettus is a Certified Holistic Nutrition and Wellness Consultant and that she does not dispense medical advice nor prescribe any treatment. Rather, she provides education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviors associated with eating. Nutritional evaluation provided in counseling is not intended for the diagnoses of disease. Rather, these assessments and health insights are intended as a guide to developing an appropriate health-supportive lifestyle program for me, and to monitor my progress in achieving my goals. While nutritional and botanical support can be an important compliment to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider.
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Yes, I understand
I understand that Robin Pettus will keep nutrition notes as a record of our work together. These notes document the topics discussed, interventions used, and treatment plan(s) that may be helpful for me. Medical records, personal information, and history divulged in session to Robin Pettus will be kept strictly confidential.
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Yes, I understand
I agree to hold Robin Pettus harmless for claims or damages in connection with our work together. This is a contract between myself and Robin Pettus, and I understand that it is also a release of potential liability. Nutrition counseling services may be terminated at the discretion of Robin Pettus, if written notification is provided to a client 30 days in advance of final appointment.
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Yes, I agree
I understand that payment is required prior to or at the time of service via Venmo, Zelle, or credit card (all major credit cards are accepted).
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Yes, I understand
Signature
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Print Name
First Name
Last Name
Submit
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