Functional Nutrition and Wellness

Functional Nutrition and Wellness

Health Coaching Intake Form
Full Name*

First NameLast Name
Date of Birth*
Contact Number*

Area CodePhone Number
Email Address*
example@example.com
Relationship Status
Occupation*
How many hours do you work per week
How concerned are you about becoming sick, experiencing suffering, or living a shortened life because of your current health trajectory or lifestyle?*

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1 is Extremely, 10 is Not At All
Have you ever worked with a Health Coach before?
How satisfied are you currently with your overall feeling of vitality and energy?*

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1 is Disappointed, 10 is Thrilled
Please list your main 3-5 health concerns or goals in order of importance.
Current Weight
Weight One Year Ago
Would you like your weight to be different?

YesNoUnsure
How many hours do you sleep per night?*
How would you describe the quality of your sleep?*
I am interested in learning more about (check all that apply):*

Healthy Eating / Weight ManagementGuided Detox ProgramsHormone HealthAging with VitalityManaging Chronic Health ConcernsMeal PrepCircadian Rhythm / Sleep SupportStress ManagementHigh Quality SupplementsSpike Protein DetoxLabwork / Toxin TestingPantry Makeover / Healthy Grocery TourToxin Free LivingOther
Check any of the following that apply to you currently:*

Joint pain or stiffnessConstipationSwellingGas or bloatingAllergies or sensitiviesDiarrheaCongestionIndigestionInflammationBrain fogWeight concernsFatigueSkin or hair changesSleep issuesHigh stress/anxietySedentary lifestyleNone of theseOther
List all serious illnesses, injuries, hospitalizations or surgeries.
Are you currently taking any medications or supplements?*

YesNo
Please list them.
Do you have any food, supplement, or medication allergies?*

YesNoNot Sure
Please list them.
Do you currently use any kind of tobacco or vape?*
What kind of tobacco/vape products do you use? How long have you used them?
Do you use any kind of recreational drugs or have you ever used them?*
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Are you currently under the care of a Physician or other health care provider?*
What role does physical activity play in your life?*
Do you cook?*
What % of your food is home-cooked?*
Describe your typical breakfast, lunch, and dinner. Include go-to snacks or treats if there are any. *
Do you crave sugar, caffeine, alcohol, nicotine, carbs, or other substances? If so, please share about it.
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Do you have someone you would consider an accountability partner?
At what point in your life did you feel your best and what were you doing that made you feel that way?*
How would you rate your current level of comfort making lifestyle changes so you can improve your long term health outcome?*

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Please share any other information about yourself that you would like us us to know.
If you are registering for a Guided Detox and Metabolic Reset Program, please share a bit about what you hope to accomplish as a result of completing this program. If not, you may skip this question.
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