Functional Nutrition Client Intake Form
Please answer all questions thoroughly and as honestly as possible. This form is confidential and the information provided cannot and will not be given to anyone without your written permission.
PERSONAL INFORMATION
Full Name:
*
First Name
Last Name
Contact Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age:
*
Date of Birth
-
Month
-
Day
Year
Date
Gender:
*
Height:
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Weight:
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Marital Status:
Single
Married
Divorced
Widowed
Occupation:
How did you hear about me?
*
Please Select
Referral
Instagram
TikTok
If referral, please list name.
*
HEALTH AND WELLNESS QUESTIONNAIRE
What would you like to change most about your lifestyle?
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List your major health concerns in order of importance:
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Check mark the box if you've had or have blood relatives with any of the following:
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Cancer
High Blood Pressure
Diabetes
Thyroid Disorder
High Cholesterol
Heart Disease
None
Other
Do you have any of the following:
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Type 2 Diabetes
Type 1 Diabetes
PCOS
ADHD
IBS
GERD
Lupus
Celiac Disease
Rheumatoid Arthritis
Anxiety
High Blood Pressure
Diabetes
Thyroid Disorder
High Cholesterol
Heart Disease
None
Other
List all prescription medicine(s) you are currently taking:
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List all vitamins, minerals, herbs, and nutritional supplements you are currently taking:
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How would you describe your general health?
What behaviors, habits or thoughts would you like to eliminate?
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Please list any skin conditions you may have and briefly describe your symptoms (ex: eczema, psoriasis, dermatitis, acne, etc):
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List your favorite foods / meals you like to eat:
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List your least favorite foods / anything you dislike eating (including condiments):
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List any foods you exclude from your diet:
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List any foods that you crave:
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Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom:
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Have you ever had or have periods of eating junk food, binge eating or dieting? List any known diet that you have been on for any amount of time:
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Please list all known food allergies, sensitivities, intolerances and/or reactions:
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Are you currently on a special diet?
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Paleo
Dairy restricted
Dairy Free
Vegetarian
Vegan
Blood Type
Raw
Refined Sugar Free
GlutenFree
Keto
None
Other
How many meals do you generally eat each day?
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One
Two
Three
Three +
How many snacks do you generally eat each day?
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One
Two
Three
Three +
What is your favorite meal of the day?
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Breakfast
Lunch
Dinner
Dessert
Do you:
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Eat out often
Diet frequently
Skip meals frequently
None
What percentage of your meals are home-cooked? Please describe:
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How much water do you drink per day?
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Do you drink more than 4 caffeinated beverages per day? (tea, coffee, soda, energy drinks)
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Yes
No
Do you put cream and/or sugar in your coffee or tea?
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Yes
No
Sometimes
Which of the following foods do you consume regularly?
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Alcohol
Soda
Diet Soda
Fast Food
Gluten (wheat, rye, barley)
Dairy (milk, cheese, yogurt)
Refined Sugar (white bread, white rice)
Coffee
None
Other
How often do you have a bowel movement?
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1-3x per day
More than 3x per day
Not regualry everyday
Do you drink alcohol?
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Yes
No
On occasion
Do you smoke tobacco?
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Yes
No
If yes, how often do you smoke?
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Do you exercise?
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Yes
No
If yes, how many times per week do you exercise?
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If yes, rate your current physical activity level:
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Low
Moderate
Heavy
Do you have trouble falling asleep?
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Yes
No
Sometimes
Do you wake up at night and can't fall back to sleep?
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Yes
No
If yes, what keeps you up?
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Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby and breastfeeding
N/A
Please rate your stress level:
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Low
Medium
High
How do you handle stress?
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At what point in your life did you feel your best? Why?
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How are your moods in general? Do you ever experience any anxiety, depression or anger?
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Is there anything else you'd like me to know about your current diet, history, or relationship with food?
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Would you like informational material for any of the following?
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Diet for children with autism
Diet for diabetics
Diet for PCOS
None
LIABILITY FORM
I am employing the nutrition counseling services of Judith Aguilar so that I can obtain information and guidance about health factors within my own control (diet, nutrition, and related behaviors) in order to support a healthy lifestyle.
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Yes, I am employing Judith Aguilar as my nutrition counselor
I understand that Judith Aguilar is a Certified Holistic Nutrition and Health and Wellness Coach and that she does not dispense medical advice nor prescribe any treatment. Rather, she provides education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviors associated with eating. Nutritional evaluation provided in counseling is not intended for the diagnoses of disease. Rather, these assessments and health insights are intended as a guide to developing an appropriate health-supportive lifestyle program for me, and to monitor my progress in achieving my goals. While nutritional and botanical support can be an important compliment to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider.
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Yes, I understand
I understand that Judith Aguilar will keep nutrition notes as a record of our work together. These notes document the topics discussed, interventions used, and treatment plan(s) that may be helpful for me. Medical records, personal information, and history divulged in session to Judith Aguilar will be kept strictly confidential.*
*
Yes, I understand
I agree to hold Judith Aguilar harmless for claims or damages in connection with our work together. This is a contract between myself and Judith Aguilar, and I understand that it is also a release of potential liability. Nutrition counseling services may be terminated at the discretion of Judith Aguilar, if written notification is provided to a client 30 days in advance of final appointment.*
*
Yes, I agree
I understand that payment is required prior to or at the time of service via Venmo, Zelle, Apple Pay, Cashapp, Cash.
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Yes, I understand
Signature
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Print Name
*
First Name
Last Name
Submit
Submit
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