GCE Health Intake form

General Health Intake form

Our main objective is to give your gut the chance to heal and how to keep it healed.
GCE Health Intake form
Name

First NameLast Name
What are your main health goals?
Flu and Vaccinations
Have you had COVID?
Do you have post COVID symptoms

Brain FogMemory LossImmune issuesMuscle weaknessDoes not apply
Have you had COVID Vaccinations?
Do you have Digestion issues?

ConstipationAcid Reflux/Heartburn/GerdBloatingDoes not apply
Joint Pain and Stiffness

InflammationTake Aspirin Tylenol oftenRestless Leg SyndromeDoes not apply
Brain Health

Brain FogMemory ConcernsFocusDepressionAnxiousness - AnxietyDoes not apply
Sleep and Energy

I sleep 8 hours a nightI am tired and fatigue in the morningI have midday fatigueDoes not apply
Female Health Concerns

PMS/Menstrual CrampsHormone ConcernsMenopause symptomsSplitting/Breaking fingernailsDoes not apply
Immunity

Sinus IssuesSubject to Colds and FluAllergiesAsthmaDoes not apply
Skin

Eczema/PsoriasisAcneIrritationDoes not apply
Let's Talk Nutrition
Do you have any food allergies or intolerances that you know of?

YesNo
List your food allergies or intolerances here
Is there other foods that irritate your stomach?
How many ounces of water do you drink daily?*
Recommended ½ your body weight in ounces. (160lbs = 80oz of water per day)
Do you eat:

Gluten freeVeganVegetarianPescatarianNone of the aboveOther
Current struggles with nutrition (check all that apply)

CravingsCommitmentPortion ControlAccountabilitySelf-DisciplineDoes not apply
Supplementation: List supplements you are currently taking:
How would you describe your current physical activity level?

Sedentary (No Physical Activity)Somewhat Active (Less than 2 hours of moderate activity a week)Active (At least 2 hours of moderate activity a week)Very Active (Over 2 hours or more of vigorous activity a week)
Do you have any physical limitations when working out that I should be aware of?
Mindset
What has stood in your way from reaching your goals in the past?*

TimeMoneyCorrect InformationNothingDoes not apply
Are you ready for a lifestyle change and invest yourself and a program to help you feel the best? (mentally and financially)

YES, I’d like to start right nowI'm ready, but still have questionsNot sure, I still have more questionsNo thank you this isn’t for me
The Nuts & Bolts
How did you find me?*

FacebookInstagramWe're friends silly!From a FriendOther
Your Information
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is your Facebook name?
What is your Instagram name?
Best way to communicate

PhoneTextEmailDM
Disclaimer

I understand that Renee VanHeel from GCE Health is not a medical professional
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General Health Intake form

GCE Health Intake form

Flu and Vaccinations

Let's Talk Nutrition

Mindset

The Nuts & Bolts

Your Information

Disclaimer