Client Intake Form

Client Intake Form

Your Balanced Diet
Personal Information
Name*

First NameLast Name
Age*
Gender*

FemaleMaleNon- binary
Email*
example@example.com
Phone Number*
Medical History and Nutrition Questionnaire
Please indicate whether you have been diagnosed with any of the following conditions:

AnemiaAsthmaBronchitisArthritis (osteoarthritis or rheumatoid)CancerPrediabetesEczemaGestational DiabetesDiabetes: Type IDiabetes: Type IIChronic Kidney Disease/ESRDHyperthyriodismIrritable Bowel SyndromeObesityDifficulty SleepingHypothryoidismHeart diseaseHigh blood fats (cholesterol, triglycerides)Hypertension (high blood pressure)PregnancyOther
What are your health goals? Provide any other detials you wish to share here.
How often do you skip meals?*

DailyOccasionally (a few times a week)Rarely (a few times a month)Never
Do you have any food allergies or intolerances? If yes, list below
Do you take any supplements or vitamins? If yes, list below
Do you exercise? If yes, select type of exercise

Stretching/YogaCardio/AerobicsStrength-trainingSports (Soccer, Swimming, etc.)Other
Our Terms and Conditions
Your health and well-being are directly influenced by your diet. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data.
Date*

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Date
Signature*

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Personal Information