Health Edge Clinic
The following intake form is being sent to you by Health Edge Clinic in leu of your upcoming consultation. Please answer all the questions to the best of your ability and submit before your scheduled appointment. If you have any questions, about this or your consultation prior to the date of, please contact us at hec@cristelbrito.com.
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Health Edge Clinic?
Social Media
Word of mouth
Friend
Event
What is your height and current weight?
*
Do you have ANY personal history of CANCER?
*
Yes
No
Do you have ANY family history of CANCER?
*
Yes
No
What current medications are you taking? Please specify.
Any allergies to any medications? If so, which medications?
*
Any previous surgeries?
Yes
No
Are you currently on or have undergone hormone or peptide therapy in the past?
*
Yes, Currently
Yes, Previously
No
Are you currently on a special diet or nutrition program?
*
Yes
No
How often do you exercise per week?
1-2
3-5
5+
What type of exercise do you do?
Weight training
Exercise clases
Combination Gym and Cardio
Walking
Yoga/Pilates
Do you have a personal trainer?
Yes
No
Are you taking any vitamins or supplements?
*
Yes
No
How much water per day are you drinking? (8 oz.= 1 portion)
0-1
2-4
5-8
8+
How many hours of sleep per night are you getting?
Less than 5
5 to 7
7+
What are your favorite 5 foods and or meals?
Pizza, sandwiches, and fast foods
Salads, protein bars, and shakes
Hearty home-cooked meals, e.g. meat and potatoes. pasta
hearty, clean, fresh-cooked, meats and veggies
How many meals a day do you consume?
live on coffee and/or air
snack all day
1-2
3+ snacks
4-6
Do you have any particular issues with appetite? (Select all that apply.)
Cravings - sugar, salt, etc.
Loss of Appetite
Stress eater
Overindulge
What is your current stress level? 1-10
1
2
3
4
5
6
7
8
9
10
Do you have a lack of sex drive or low libido?
Yes
No
What is your occupation?
Do you work long hours?
Yes
No
Do you consume alcohol?
Yes
No
Social drinker
More than social
Do you smoke?
Yes
No
Socially
More than Social
How many times a month do you get spa and/or massage treatments?
0
2-4
5+
Do you shop organic food and household products?
Yes
No
How satisfied are you with your current weight? 1-10
1
2
3
4
5
6
7
8
9
10
How would you rate your current body composition? 1-10
1
2
3
4
5
6
7
8
9
10
What level would you say your daily energy is? 1-10
1
2
3
4
5
6
7
8
9
10
How would you rate the quality of your skin? 1-10
1
2
3
4
5
6
7
8
9
10
What would you like to improve about your health and wellness?
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