Client Intake Form 2026

Langlois' Vital Nutrition Center, Ltd
We now save credit cards on file to take pre-payment for your initial consultation. A member of our staff will call to take down payment info, and to take that initial consult fee.

You will also be charged for missed appointments and recurring cancellations less than 24 hours. See our missed appointment policy for details.
How Did You Hear About Us?*
Practitioner*
Personal Details
Full Name*
Age*
Birthdate*

MonthDayYear
Date
Gender*
Phone Number*
Email*
example@example.com
Address*

Street Address

Unit/Apt/Building Number

CityState / Province

Postal / Zip Code
Height
Weight
Ideal Weight
Occupation*
Marital Status*

MarriedSingleDivorcedWidowed
Military?*

YesNo
Family members or pets in the household?*
Priorities
4 Main Goals (Prioritized)
1. * 2. *
3.Type a label 4.
What are you most looking to get out of these services with us?*
What do you see being your biggest challenge for you to accomplish your goals?*
How willing are you to make adjustments with your time social life finances and even sleep to achieve these goals?*
What will you absolutely not give up or change?*
What is one area you know you can change now to improve how you feel?*
Is there anything that scares or intimidates you about following a nutrition plan?*
Share any previous experience with alternative practitioners or what you have tried.
Medical History
If you are currently under the care of a medical professional, please list name, clinic, and date.
Blood Type
Do you regularly get vaccinated for flu covid or other?*
Have you ever taken any of the following? (check all that apply)*

MolybdenumPrenatalSynthetic Vitamin C (Ascorbic Acid)IronCalciumZincVitamin D3Drug Store One-a-day MultivitaminsHigh Fructose Corn SyrupFlouride
Have you ever had any iron infusions?*

YesNo
Have you had any surgeries? If so, when?
Do you have any medical diagnoses?
Any Mercury/Metal Fillings?*

YesNo
Have you had any metal fillings removed?*

YesNo
Any root canals?*

YesNo
List any special diet or dietary restrictions/why (ex Gluten-free, Low Fodmap, Low Oxalate)
Any allergies?
Females
Check one:

Mensural CyclingPerimenopauseMenopausePost Menopause
If under the age of menopause, do you currently get a cycle/period?

YesNo
Are you pregnant or breastfeeding or having difficulties getting pregnant?
What have been the characteristics of your menstrual cycle or post menopause?
Do you use birth control or hormone replacement therapy?
If you have been on birth control how long?
If you have stopped birth control, when?
Intake
How much water do you drink in a day?*
Do you use a filter for drinking or shower water? Yes No
If so, What kind?
Type kind
What other beverages do you drink and how much?*
What do you use for sweetener? (sucralose found in most energy drinks count)*
Are you usually hungry for breakfast?*

YesNo
What do you typically eat for breakfast, lunch, and dinner?
Breakfast*
Lunch*
Dinner *
Do you follow a fasting schedule?*

YesNo
Would you say you have a negative relationship with food?*

YesNo
Do you get cravings? If so, for what? When?
Mostly eat from:*

Usually home cookedEat out a lotAbout half and half
Where and how do you typically eat? (ex. standing while working at the table, with family, on the go)*
Movement
Do you exercise?*

YesNo
If so how?
Do you enjoy it?*

YesNo
What time of the day do you typically work out? time*
How do you feel when you are finished? Feel?*
How often do you have a bowel movement?*
Is it difficult easy or do you get the runs?*
Do you have any digestive issues like: pain, bloating, acid reflux, or flatulence?*
What time do you go to bed? Bed time* Wake? Wake time*
How many hours of restful sleep do you typically get?*
Do you wake with pain?   Yes   No
Does it go away upon moving?   Yes   No
Do you feel rested when you wake?      Yes   No
Stress Assess
What do you do to relax?*
Rate your stress level:*

Low 1Medium 2High 3
What is your current living situation?*

StableAbout To MoveRecently MovedIts Complicated
Do you have anyone you are supporting in an ongoing way? (grown kid or family member? etc)*
Are there any environmental exposure concerns you are facing?
Mold at home or work High chem exposure at work Known water issues
Other
How would you describe your childhood?*

StableMoving constantlyTraumaticSafe & enjoyableSick a lotHard
Have you smoked cigarettes or cigars?*
Recreational use of drugs? (confidential)
Do you drink alcohol? If so how much and how often?*
Extra relevant info:
Missed Appointment Policy

At Langlois' Vital Nutrition Center, we ask our clients for a minimum of 24-hours notice for all appointment cancellations or reschedules. This provides respect to our practitioners, their time, and affords them the option to help as many clients as possible within the time they have made available.

We understand that life is unpredictable and occasions may arise that require you to change appointments, so we have implemented a "3-Strike" Policy for appointments canceled less than 24-hours in advance of the scheduled appointment time:

Strike 1: No charge.

Strike 2: Client will be charged 50% of the appointment fee

Strike 3 Client will be charged a fee equivalent to consultation price
Initial Here That You Understand*
Date*

MonthDayYear
Date
   Medications and Supplements List
First and Last Name   Date
Name and Brand / Dose
Name and Brand   Dose
Name and Brand   Dose
Name and Brand   Dose
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Name and Brand   Dose
Name and Brand   Dose
Name and Brand   Dose
Name and Brand   Dose
Name and Brand   Dose
Name and Brand   Dose
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Take Photo
Should be Empty:

Personal Details

Priorities

Medical History

Females

Intake

Movement

Stress Assess