INDIGO Intake Form
Hello Beautiful!
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Birthday:
Height:
Current Weight:
Desired Weight:
Occupation
Please rate your level of stress from 1 to 10 with 1 being little stress.
Do you commit to being your most brilliant and imperfect self? Are you ready to be uncomfortable at times and pushed from your comfort zone?
How would you rate the pace of your life? Busy, moderate, or relaxed?
Do you have any digestive troubles, such as: constipation, diarrhea, IBS, Colitis, bloating?
How do you sleep at night?
How much water do you drink per day?
Do you have any food challenges? Eating when bored? Portion control?
Are you addicted to any of the following: caffeine, sugar, alcohol, cigarettes?
How often do you exercise? And what types of exercise do you enjoy?
Please list any supplements or medications that you take:
Please list any therapy, massage, coaching that you do:
Please list your typical foods for breakfast:
Lunch
Dinner
Snacks
Beverages
What would you like to be different 6 months from now? Physically, spiritually, mentally, and/or emotionally?
What is holding you back?
Any history of family health problems?
Please verify that you are human
*
Submit
Should be Empty: