Client Intake Form
Please answer these questions openly and honestly to help me give you the best advice on how to reach your health and wellness goals. The more in-depth you go the better I can support you.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth
*
-
Month
-
Day
Year
Date
Height (cms)
*
Current Weight (kgs)
*
Goal Weight (kgs)
Movement Level — Please tick the one that describes your typical day:Daily Movement Level:
*
Sedentary (desk job, minimal daily steps)
Lightly Active (some walking, on feet often)
Moderately Active (on feet a lot, 8k–12k steps daily)
Very Active (physical job, high step count)
Extremely Active (labour intensive work, very high activity)
Exercise Level:
*
No exercise
1–2 sessions per week
3–4 sessions per week
5+ sessions per week
Progress Photos Consent (Non-Identifying Only):Your face will never be shown.Images are only used to track your progress visually.
*
Yes, I consent to providing non-identifying progress photos
No, I do not consent
Do you have any diagnosed medical conditions?(e.g., thyroid issues, PCOS, endometriosis, depression, anxiety, insulin resistance)
*
Do you have any current or past injuries?
*
Do you have any digestive issues?
*
Bloating
Excessive Gas
Diarrhoea
IBS
Reflux
None
Current medications/supplements:
*
Sleep patterns (hours per night):
*
4-5
5-6
6-7
7-8
8+
Stress levels
*
Low
Moderate
High
Overwhelming
Mental health considerations relevant to coaching:(Anxiety, binge eating patterns, emotional triggers, etc.)
*
Tell me about your dieting history.(Programs, diets, restrictions, emotional patterns)
*
What has held you back in the past?(all-or-nothing, emotional eating, lack of time, overwhelm, fear of failure)
*
Describe a typical weekday for you:(work, kids, stress, meals, movement)
*
Who do you cook for?
*
Just me
Me and partner
Me and child/children
Larger family
Other
How many meals do you cook at home?
*
Almost All
Half
Very few
What is your grocery budget per week?
*
Foods You LOVE (must include):
*
Foods You DISLIKE (never include):
*
Foods You CANNOT eat (medical/allergies):
*
Foods You Tend to Overeat or Struggle With:
*
Chocolate
Chips
Bread
Pasta
Takeaway
Soft drink
Sugary foods
Other
Meal Types You Want in Your Plan:
*
High protein meals
Quick 10–15 minute meals
Slow cooker meals
Family-friendly meals
Budget-friendly meals
Meal-prep friendly
2–3 meals repeated weekly
Lots of variety
Other
Breakfast Style You Prefer:
*
Same breakfast daily
2–3 options rotated
Fast/no cooking
Savoury
Sweet
Lunch Style You Prefer:
*
Simple + quick
Meal-prepped
Fresh salads/wraps
Leftovers
Other
Dinner Style You Prefer:
*
Family meals
Low effort
Slow cooker
Tray bakes
Pasta/rice based
Foods you MUST have in your lifestyle (e.g., chocolate, coffee, wine).
*
Foods You Want to Reduce But Not Eliminate:
*
Snacks you enjoy
Do you emotionally eat? If yes, what triggers it?
*
Do you experience all-or-nothing thinking?
*
Yes frequently
Sometimes
Rarely
Describe your current relationship with food:
*
Chaotic
Restrictive
Emotional
Uncertain
Improving
Balanced
What support do you need from me as your coach?
*
From time to time, The Wellness Nutrition Co may send emails containing nutrition education, free resources, product updates, promotions, and special offers.
*
Yes, I consent to receiving marketing emails from The Wellness Nutrition Co and understand I can unsubscribe at any time.
No, I do not wish to receive marketing communications.
By submitting this form, you confirm that: • All information provided is true and accurate • You consent to personalised nutrition coaching • You understand the coaching boundaries and terms • You consent (or decline) progress photo usage as selected above • You consent (or decline) marketing emails as selected aboveSignature (typed or digital):
*
Date
*
-
Month
-
Day
Year
Date
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