Metacrux Client Intake Form
Client intake for diabetes lifestyle coaching. Please answer all questions as completely as you can. Include any recent lab reports or a photo of your medication list if available.
About You
Full Name
*
First Name
Middle Name
Last Name
Preferred Name / Pronouns
Age
*
Gender
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
City / Time Zone
*
Occupation / Typical Work Hours
How Did You Hear About Us?
Preferred Contact Method
*
Phone
Email
Text Message
Other
Best Time to Reach You
*
Morning
Afternoon
Evening
Weekdays
Weekends
Other
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Relationship to Emergency Contact
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Diabetes & Medical Background
Diabetes diagnosis
*
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
Prediabetes
MODY
LADA
Other
Year diagnosed
A1C (%)
A1C test date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Typical fasting glucose value
Height
Current weight
Cholesterol (LDL / HDL)
Other health conditions
High blood pressure
High cholesterol
Heart disease
Kidney disease
Thyroid condition
PCOS
Sleep apnea
Depression or anxiety
Liver disease
Other
Diabetes-related complications
Eye disease
Kidney problems
Nerve pain or numbness
Foot problems
Heart disease
Stroke
Gastroparesis
None
Other
How often do you have low blood sugar episodes?
Never
Less than once a month
1-3 times a month
1-2 times a week
3 or more times a week
Not sure
Other
Do you feel symptoms when your blood sugar is low?
Always
Usually
Sometimes
Rarely
Never
Not sure
Other
Have you needed help from someone else to treat a low blood sugar episode in the past year?
Yes
No
Not sure
Medications/devices
Blood Sugar Monitoring
How do you check your blood sugar?
*
Fingerstick meter
Continuous glucose monitor (CGM)
Flash glucose monitor
Other
How often do you check your blood sugar?
*
Before meals
After meals
Fasting
At bedtime
When I feel symptoms
Only as needed
Other
Are you willing to share your glucose data with your coach?
*
Yes, I can share app screenshots or reports
Yes, I can grant access through an app
Yes, but only occasionally
Not at this time
Other
Health apps or trackers used
Patterns you've noticed
Eating & Nutrition
Which best describes your current eating pattern?
Mostly home-cooked meals
Mix of home-cooked and convenience foods
Frequent takeout or restaurant meals
Often skip meals
Irregular eating schedule
Other
Breakfast: usual time
Breakfast: usual foods and drinks
Lunch: usual time
Lunch: usual foods and drinks
Dinner: usual time
Dinner: usual foods and drinks
Snacks: usual time
Snacks: usual foods and drinks
Late-night eating: usual time
Late-night eating: usual foods and drinks
How often do you eat fast food or takeout?
Never
Less than once a week
1–2 times a week
3–4 times a week
5 or more times a week
Other
How often do you drink sugary beverages?
Never
Less than once a week
1–2 times a week
3–4 times a week
5 or more times a week
Other
How often do you eat vegetables?
With most meals
Once a day
A few times a week
Rarely
Never
Other
How often do you eat while distracted?
Never
Rarely
Sometimes
Often
Very often
Other
How many cups of water do you drink per day?
Who usually does the grocery shopping and cooking?
What are your biggest food challenges?
Cravings
Portion sizes
Eating out
Time to cook
Budget
Meal planning
Late-night eating
Emotional eating
Snacking
Family preferences
Other
Foods you love and do not want to give up
Physical Activity & Movement
Current activity level
*
Sedentary
Lightly active
Moderately active
Very active
Activities you do now
Walking
Strength training
Cycling
Swimming
Yoga
Running
Sports
Household chores
Other
Days per week active
Minutes per session
Hours sitting per day
Exercise limitations description
Injuries, pain, or mobility limitations
Barriers to moving more
Lack of time
Low energy
Pain or discomfort
Weather
Low motivation
No safe place to exercise
Cost
Caregiving responsibilities
Other
Activities you enjoy or would like to try
Sleep, Stress & Mood
Hours of sleep per night
Usual bedtime / wake time
Shift work or irregular schedule
Yes
No
Sometimes
Other
Sleep quality
Very poor
Poor
Fair
Good
Very good
Other
Snoring, waking up tired, or diagnosed sleep apnea
Snoring
Wake up tired
Diagnosed sleep apnea
Other
Stress level
No stress
Mild
Moderate
High
Very high
Other
Main sources of stress
Work
Family
Finances
Health
Relationships
Caregiving
School
Other
How do you usually cope with stress?
Burned out or discouraged about managing diabetes
Not at all
A little
Moderately
A lot
Other
Alcohol use
Never
Occasional
Weekly
Daily
Stopped
Other
Support, Goals & Motivation
Support at home
Family
Partner/Spouse
Roommate
Friends
Caregiver
Other
Main goals
*
Improve blood sugar control
Lose weight
Build healthier eating habits
Increase physical activity
Improve sleep
Reduce stress
Build a consistent routine
Other
In 3 months, what would make you say "this was worth it"?
Why is this important to you right now?
What has worked for you before? What hasn't?
How motivated are you to make changes?
*
Not at all motivated
1
2
3
4
5
6
7
8
9
Extremely motivated
10
1 is Not at all motivated, 10 is Extremely motivated
How confident are you that you can make changes?
*
Not at all confident
1
2
3
4
5
6
7
8
9
Extremely confident
10
1 is Not at all confident, 10 is Extremely confident
How ready are you to start this week?
*
Not ready
1
2
3
4
5
6
7
8
9
Ready to start
10
1 is Not ready, 10 is Ready to start
Coaching Preferences & Logistics
What support do you want most?
*
Meal planning and nutrition
Blood sugar management
Medication organization
Physical activity routines
Stress management
Sleep habits
Accountability and motivation
Problem-solving daily challenges
Other
Preferred coaching style
*
Direct and structured
Supportive and encouraging
Practical and action-focused
Open-ended and reflective
Accountability-focused
Other
How do you learn best?
Talking things through
Written summaries
Visual examples
Step-by-step instructions
Videos or demonstrations
Trying things hands-on
Other
Any concerns or fears about starting coaching?
Anything that would make it hard to attend sessions
Anything else you'd like your coach to know
Privacy notice: Any documents or information you share will be kept private and used only to support your coaching care.
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