Client Intake Form
Please answer each question in as much detail as possible! Thank you!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age/Gender/Height/Weight
How would you categorize your goals and needs? Check all that apply!
Weight loss/body recomp
Muscle/strength gain
Increase athletic performance
Improve symptoms of autoimmune/health condition
Hormonal concerns
Blood sugar regulation concerns
Gut health concerns
Liver function concerns
High cholesterol and/or blood pressure concerns
General nutrition & lifestyle
Sleep & stress concerns
Other
How many days a week do you workout or do some sort of intentional movement/activity?
Please describe your exercise/training/activity/workout regime in detail. (Type of exercise, average duration of session, average intensity level...etc)
How would you rank your current performance level when you workout? (0=awful, 5=I feel like a champion)
Please Select
0
1
2
3
4
5
Are you chronically sore from your workouts?
Yes, always
No, never
Occassionally
Do you have any chronic joint/muscle pain or nagging injuries?
Yes
No
If you answered "yes" to the above question, please describe the pain/injury in detail.
How would you describe your food intake in general? Check all that apply!
I literally eat everything and anything.
Vegetarian
Pescatarian
Vegan
Dairy free
Gluten free
Soy free
Paleo-ish
Low FODMAP
I watch my sugar intake
Mostly processed foods
How many meals a week are eaten out or ordered in?
How many alcoholic drinks do you consume on a weekly basis?
How much water do you drink in a day?
Please list any current supplements or vitamins you are taking and why.
Walk me through an average day of eating. Meal timing, types of food, portions; breakfast, lunch dinner, snacks; in as much detail as possible.
How would you rank your hunger levels throughout the day? (0=never hungry/forget to eat, 5=I love food and could eat all day)
Please Select
0
1
2
3
4
5
How would you rank your energy levels throughout the day? (0=sitting up is difficult, I want to nap all day, 5 = I'm an energizer bunny!)
Please Select
0
1
2
3
4
5
Do you suffer from brain fog?
Yes
No
Sometimes
Do you drink caffeine and if so, how many drinks do you consume in a day?
What time do you go to bed? Can you fall asleep easily or do you take anything to help fall asleep?
Do you sleep through the night? If not, how often do you wake up?
What time do you wake up in the morning? Do you need an alarm? If so, do you press snooze often?
How would you rank your average sleep quality? (0=I sleep horribly and never feel rested, 5=you couldn't wake me if a parade came through my house)
Please Select
0
1
2
3
4
5
How would you rank your current stress levels? (0=I'm super chill, 5=I could break down at any moment)
Please Select
0
1
2
3
4
5
Do you have or have you experienced chronic depression and/or anxiety?
Yes
No
Are you currently taking any medications? If so, please list them below and the reason for taking them.
Do you have any specific health conditions that you're concerned about or does anything run in your family that you'd like to avoid?
FEMALES: Are you currently on hormonal birth control?
Yes
No
FEMALES: If you answered NO, have you been on hormonal birth control in the past and how long have you been off it? If you answered YES, what type are you on and how long have you been on it?
FEMALES: Is your cycle regular?
Yes
No
FEMALES: Do you experience PMS symptoms and if so, please list them and describe the severity.
FEMALES: Do you experience frequent yeast infections?
Yes
No
Do you have any specific hormone and/or thyroid concerns and if so, what are they?
Do you experience any of the following GI issues? Check all that apply!
Constipation
Diarrhea
Gas
Bloating
Heartburn/acid reflux
Nausea
Belly aches
Vomitting
Do you have bowel movements daily?
Yes
No
Do you experience any skin related issues? Check all that apply!
General acne
Cystic acne
Eczema
Rashes
Dry skin
Itchy skin
Bumps on the back of arms
Do you have any food allergies or sensitivities and if so, please list them out along with the symptom/reaction they give you.
Do you have a history of any type of disordered eating behavior?
Yes
No
Please share any other noteworthy information you think I should know before our official call! :) Thank you for taking the time to fill this out and I look forward to chatting with you!
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