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
Male
Female
-
Area Code
Phone 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
Lifestyle & Habits
Daily Activity Level
Sedentary
Lightly Active
Moderately Active
Very Active
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?
0
1
2
3
4
5
6
7
8
9
10
Dietary Patterns
Current Diet Type
Fasting(But I eat fish)
Fasting ( Don’t eat Fish)
Non-Fasting
Carnivore
Pescatarian
Vegetarian
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?
Submit
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