Client Intake Questionnaire

Client Intake Questionnaire

Welcome! Thank you for choosing to work with APEX Nutrition. To design a meal plan that truly fits your life, please be as detailed as possible in your responses. All information provided is strictly confidential and will be used solely to personalize your nutritional strategy. Estimated time to complete: 10–15 minutes.
Personal Details
Ex. February 7th, 2003
Gender
Area CodePhone Number
Eg. weight loss, muscle gain, managing condition, improving energy levels
Biometrics
Medical & Health History
Please list all medical conditions (e.g., Diabetes, PCOS, Hypertension, IBS)
Please list all triggers and reaction severity
Please list everything currently being taken
Do you have any current or recurring injuries?
Please describe your injury in detail.
How would rate your daily pain level?
Have you seen a Doctor, Physiotherapist, or Chiropractor for this?
What was their official diagnosis or advice?
Are you currently taking any medication or supplements for inflammation or pain?
What specific movements or exercises trigger the pain?
What is your current mobility like?
Eg. I can’t touch my toes, I can’t lift my arm above my head, etc…
What is your primary goal regarding this injury?
Lifestyle & Habits
Daily Activity Level
What type of movement do you do? How often and for how long?
How many hours do you average, and do you wake up feeling rested?
Stress Levels : How would you rate your daily stress?
Dietary Patterns
Current Diet Type
Describe your standard breakfast, lunch dinner and snacks in a typical day
Are there specific times of day or emotions that lead to overeating?
How comfortable are you in the kitchen? How much time do you realistically spend prepping meals?
Should be Empty:

Client Intake Questionnaire

Personal Details

Biometrics

Medical & Health History

Lifestyle & Habits

Dietary Patterns