New Client Intake Form

1

Client Name

2

Date

3

Preferred Name if different

4

Pronouns optional

5

Date of Birth

Date

6

Email

7

Phone

8

1. Reason for Seeking Health Coaching Please briefly describe what brought you to health coaching at this time

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Please briefly describe what brought you to health coaching at this time:

10

1b. What are your top 1-3 goals for our work together?

Goal 1

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Goal 2

12

Goal 3

15

2c. Please list any current medical conditions or concerns

16

2d. Are you currently under the care of a medical provider?

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3. Medications & Supplements Please list any medications, supplements, or herbal products you currently take (include dosage if known):

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3b. Do You Have ANY Food Allergies or Sensitivities?

Yes

No

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4. How would you describe your current eating pattern?

Balanced

Inconsistant

Highly Structured

Emotional/ Stress Related

Not Sure

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4c. How many meals do you typically eat per day?

1-2

3

4+

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4d. How would you rate your relationship with food?

Challenging

Neutral

Mostly Positive

Very Positive

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4e. What nutritionrelated changes are you hoping to make

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5. How would you rate your current stress level?

Low

Moderate

High

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5d. What does emotional balance look like for you?

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6. How many hours of sleep do you typically get per night?

less than 5

5-6

7-8

9+

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6b. How would you rate your sleep quality?

Poor

Fair

Good

Very Good

30

6c. How often do you engage in physical movement?

Rarely

1-2x Per week

3-4x Per week

5x or more Per week

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6d. What types of movement do you enjoy

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What support or accountability helps you most?

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Is there anything else you'd like me to know about your health lifestyle or goals?

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I understand that health coaching is not a substitute for medical care and that I am responsible for my own health decisions.

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Client Signature

37

Date