Hello Health!
Explorative Intake Form
Full Name
First Name
Last Name
Email
example@example.com
Best Number for your Assessment Call
Please enter a valid phone number.
Best Date for your Assessment Call
-
Month
-
Day
Year
Date
How did you hear about this/ who referred you?
What are your current health goals? (Mental, Emotional, Physical, Spiritual)
Why you are interested in getting healthy? (What is your main motivation? Relationships, activities, how you feel, etc)
Health Intake
Please list all allergies.
Please list all supplements and medications you are currently taking.
Sleep
How many hours do you typically get?
On a scale of 1-10, (10 is Excellent) rate your overall quality of sleep.
Hydration
How much water are your drinking per day
Do you consume
Tea
Coffee
Alcohol
Soda
Recreational substances
Energy Expenditure
How would your rate your daily energy 1 (lowest) to 10 (highest)?
Do you currently exercise? If yes, how many times per week?
What activities do you participate in?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
VERY active
Stress
How would your rate your stress level 1-10 (10 HIGH Stress)
What do you do for work?
What are the 3 top stressors in your life?
Eating Habits
How many meals do your eat per day?
Do you snack?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
What are some of your favorite foods?
Weight
Type a questionIs weight or metabolism a category of health you are looking to improve?
Yes
No
If yes, continue answering:
Current Weight and Height
In a perfect world, if you could not fail, how many pounds would you want to lose?
What has been the most difficult thing about losing weight in the past?
Success often thrives with support: Is there anyone in your life who would like to get healthy with you? What is their name?
Emotional/Spiritual
On a scale of 1-10 (10 UNREGULATED), how would you rate your ability to regulate your emotions?
What emotions do you struggle with the most?
What does your spiritual life/practice look like? Are you affiliated with any religion/community
What types of tools do you practice/include regularly?
Meditating
Bodywork/energy sessions
Books/Podcasts
Talking to friends
Therapy
Other
Other:
What are some "bad habits" you struggle with?
What things have your tried/done in the past to support you with these goals? What worked, what was missing?
What is something you are looking forward to? (Today, an event, anything!)
What are 5 things that bring you joy? :)
Congratulations! Thank you for taking time to fill out this form and getting to know yourself a little more. Sarah will reach out shortly.
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