Health Intake Form 01

Health Intake Form
Practitioner Name
Your information will be shared with your practitioner
Practitioners email
Your Full Name*
First Name, Last Name
E-mail*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone*

Country CodeArea CodePhone Number
Your Age
Gender
Relationship Status

SingleIn a relationshipMarriedDivorcedWidowedIt's complicated
HEALTH INFORMATION
Energy Level

(1 Poor - 5 Excellent)
Sleep

(1 Poor - 5 Excellent)
Life

(1 Stuck/Lost - 5 On Track & Thriving)
Relationships (Friends/Romantic)

(1 Poor - 5 Excellent)
Fitness | Exercise

(1 Coach Potato - 5 Gym Bunny)
Physical Body

(1 Not happy with my body - 5 In perfect shape)
Mind | Thinking | Memory

(1 Poor - 5 Excellent)
Muscles | Bones | Joints

(1 Poor - 5 Excellent)
Skin

(1 Poor - 5 Excellent)
Eating | Digestion | Elimination?

(1 Poor - 5 Excellent)
Current weight
In LBS or KG please
Ideal weight
In LBS or KG please
What do you most want to make progress on?
More Information
Current Diet

Omnivore 1 (High in plants, Low in processed/fried foods)Omnivore 2 (Low in plants, High in processed/fried foods)Vegetarian / Vegan (Plant based)Other
H2O (water/herbal tea) per day?

1 - 4 glasses5 - 10 glasses2 Liters/gallon +
Please select what applies to you

Drink more than 2 coffees per dayGreat cookPoor cookOften on the roadOften eat aloneLive aloneLive with other peopleConfused about good food/nutritionTime constraintsPoor snack choicesOften crave sweet snacksProne to accidentsFast eater
Anything else about your nutrition/eating habits?
Comments - Questions
Record in your own words what you'd like help with
Any relevant document or image you wish to share?

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Health Intake Form

HEALTH INFORMATION

More Information