Client Intake & Metabolic Health Profile
Welcome, and thank you for taking this step toward improving your health and well-being. This intake form gathers important information about your health history, lifestyle, and goals so I can provide the most appropriate coaching and integrative wellness support. My approach combines structured metabolic health coaching with whole-person wellness support to help you restore energy, improve metabolic function, and create lasting, sustainable results. All information provided is strictly confidential and used solely for coaching and wellness planning purposes. Please answer thoughtfully and honestly.
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of communication:
*
Text
Email
Phone Call
No phone calls unless scheduled
Date of Birth (optional)
Occupation
Your Health Vision
Where are you in your health today?
Where would you like to be in your health over the next 3–6 months?
If you could not fail, what would you most love to change about your health?
What is motivating you to improve your health at this time?
When was the last time you felt your best physically and mentally?
What has changed since then?
Health History
Please check any that apply
Weigh gain
Fatigue or low energy
Sleep disturbances
Hormonal changes
Thyroid condition
High blood pressure
Diabetes or blood sugar concerns
Digestive issues
Chronic stress
Anxiety or depression
Inflammation or pain
None
Other
Are you currently under the care of a physcian?
*
Yes
No
List any medications and/or supplements
*
Lifestyle & Daily Habits
How many hours of sleep do you get per night?
Is your sleep restful?
Rate your stress level on a scale of 1-10
Rate your energy level on a scale of 1-10
How much water do your drink daily?
Do you consume
Coffee
Tea
Soda
Alcohol
Other
Describe a typical day of eating
How often do you engage in intention physical activity?
Readiness & Support
On a scale of 1–10, how ready are you to make meaningful changes to your health?
What challenges have prevented progress in the past?
What type of support helps you most?
Accountability
Structure
Education
Encouragement
Emotional Support
All of the above
Metabolic Health Goals
What are your primary goals? (check all that apply)
Weight loss
Improved energy
Better sleep
Improved metabolic health
Improved confidence
Overall wellness
Integrative Wellness Support (Optional)
Empowered Energy & Wellness offers integrative services to support nervous system regulation, stress reduction, and overall well-being.
Please indicate interest if applicable:
Reiki
Sound Therapy
Meditation Support
Not at this time
Section 8: Agreement & Confidentiality
Empowered Energy & Wellness provides metabolic health coaching and integrative wellness support designed to improve lifestyle habits, metabolic health, and overall well-being. These services do not diagnose, treat, or cure medical conditions and are not a substitute for licensed medical care. Clients are encouraged to work with their healthcare provider for medical concerns. All information provided is strictly confidential and used solely for coaching and wellness planning purposes.
By signing below, I acknowledge that I have voluntarily provided this information and consent to participate in coaching and wellness services.
Signature
Date
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Month
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Day
Year
Date
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