Intake Form
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
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Occupation
How did you hear about me?
Contact Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail that we will use to regularly communicate with you
*
Preferred phone number for voice and/or text communication
*
-
Area Code
Phone Number
What is your preferred method of communication?
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Health Information and History
Please select all that apply below.
Musculoskeletal
Joint Pain
Muscle Pain
Stiff joints
Headaches
Chronic pain
Cardiovascular System
High Blood Pressure
Angina/Chest Pain
Heart Disease
Cold Hands/Feet
Clotting Disorder
Varicose veins
Respiratory
Shortness of Breath
Tight or congested chest
Wheezing
Cough
Asthma
Neurological
Fainting
Dizziness
Numbness/Tingling
Seizures
Headaches or migraines
Memory Loss
Problems with sleep
Endocrine System
Hypothyroidism
Hyperthyroidism
Sugar cravings
Type 1 Diabetes
Type 2 Diabetes
Hormone imbalance
PMS symptoms
Irregular periods
Hashimoto disease
Digestive System
Stomach Pain
Nausea
Vomiting
Heart Burn
Gas
Change in Appetite
IBS
Inflammatory bowel disease
Celiac Disease
Gall Bladder removed
Hemorrhoids
Diarrhea
Constipation
Mental/Emotional Health
Depression
Anxiety
Insomnia
Mood Swings
Anger/Frustration
Irritability
Phobias
Panic Attacks
Please list anything else, or elaborate on the above if you would like.
Please list surgeries.
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Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..
Yes
No
Please list below
Are you taking any supplements, minerals/vitamins, herbs or other natural health care products including protein powder and pre-workout if applicable?
Yes
No
Please list below
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Dietary and Lifestyle Habits
How often do you exercise?
0
1
2
3
4
5
6
7
Times per week
What kind of exercise?
Do you have physical limitations with certain exercises?
Yes
No
If yes, please explain.
What do you like about your current workout regimen and what would you like to change?
Do you have access to a gym or do you have equipment at home? If so, what equipment do you have access to?
Do you have any known (or suspected) food allergies or intolerances?
Yes
No
Please list:
Do you have any dietary restrictions? (eg. religious, vegan/vegetarian)
Yes
No
Please specify
Average number of bowel movements per day
Do you experience any of the following (check all that apply)
Straining
Blood in stool
Mucus in stool
Diarrhea
Constipation
Please indicate how many cups of the following you drink per day,based on a standard mug size.
0
1
2
3
4
5
6
7
8
9+
Water
Coffee
Tea
Herbal Tea
Juice
Cola
Do you smoke tobacco?
Yes
No
In the past
Do you consume alcohol?
Yes
No
How many days per week?
1
2
3
4
5
6
7
1 is , 7 is
Typically, how many drinks do you have when you do drink?
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Sleep, Energy and Stress Levels
Please rate your energy level on a scale from 1-10
1
2
3
4
5
6
7
8
9
10
Lowest
Highest
1 is Lowest, 10 is Highest
On average, how many hours of sleep do you get?
Less than 5
5-7
8-9
9-11
Do you have difficulty falling asleep?
Yes
No
Sometimes
Do you have difficulty staying asleep?
Yes
No
Sometimes
Do you nap during the day?
Yes
No
Sometimes
Please rate your stress level on a scale from 1-10
1
2
3
4
5
6
7
8
9
10
Lowest
Highest
1 is Lowest, 10 is Highest
What are some stressors in your life?
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Personal And Plans
Height
Weight
Please provide a description of your goals in detail. What do you wish to achieve with Roper Wellness?
What diets have you tried (with or without success)?
Please give a summary of your daily schedule and activities on an average weekday and weekend day.
Please provide pictures of yourself for body composition analysis. Please wear a sports bra and shorts and take a picture from the front, side, and back.
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Please enter your food log for a 5-7 day period. Be as accurate as possible, including snacks and drinks. Or you may upload photo below of log as well.
Food log
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Please feel free to add any other relative information you would like for me to know.
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