Client Intake Form

Client Intake Form

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Full Name*

First NameLast Name
E-mail*
example@example.com
Birth Date*

MonthDayYear
Weight*
Height*
Goal*
If you are unsure of what your goal is just choose maintenance as I will be assessing your eating habits and I will decide what the best course of action is.
Level of Activity*
Current Nutrition and Exercise *
Describe a typical day. Be as detailed as you can. Be totally honest.
Dieting History*
Why do you want to make a change?
Do you have any medical issues?
Terms & Conditions

I agree that these statements are true to the best of my knowledge. I will be open and honest about my current dietary habits and give permission to my nutrition coach to advise the best nutrition plan for me. I will abide by the guidelines to the best of my ability and keep open communication at all times.
Signature*

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