Health Intake Form

Please complete this form and submit in advance of our first session. You may leave any section blank that you wish. If you would prefer to download a paper copy, please contact me at coachneshama@gmail.com. Thank you!

Full Name*

First NameLast Name

Gender pronouns:

Gender Identity

E-mail*

Cell Phone Number*

Area CodePhone Number

Do you text?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Contact

First NameLast Name

Emergency contact cell phone

Area CodePhone Number

Emergency contact is my

Date of Birth

MonthDayYear

Age

Height

Current Weight, if known

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different?

If yes, what would be your ideal weight?

When was the last time you weighed that amount?

Relationship status

Comments about relationship status, if any

Children (if yes, ages)

Pets (if yes, type and #)

If you work (in or outside the home) how would you describe your occupation?

If you work, do you enjoy what you do?

What would be your dream job?

Are you experiencing any of the following?

Overall, how much stress do you feel like you are experiencing in your life right now?

How long have you been experiencing these stressors:

If you wish to elaborate about any stress you are experiencing:

Are you experiencing any of the following:

Please feel free to provide history/detail for list above:

Digestion - do you experience any of the following (check all that apply):

Please feel free to provide history/detail for list above:

Please list any food allergies or sensitivities:

Please list your main health concerns:

At what point in your life did you feel your best?

Have you had any serious illnesses, hospitalizations or injuries?

Have you ever experienced a traumatic event?

If you wish to share info about trauma, include here:

Do you sleep well?

How many hours per night?

What is your typical sleep schedule?

Do you have a usual "routine" prior to going to sleep?

Do you have a primary care physician?

Have you had a physical in the last 12 months?

Please list any therapists, holistic practitioners or physicians you are currently working with:

Please list any supplements or medications you are taking:

What do you do for movement / exercise? How often?

Do you do any of the following practices?

What is your typical morning routine?

Food & Diet Specifics Follow (please answer to the best of your ability)

Think back over the last 24 hours. Please list everything you remember eating & drinking. (This is meant to be a "snapshot").

What do you typically eat and drink for breakfast on weekdays?

What time do you normally eat breakfast on weekdays?

Where do you usually eat breakfast?

Is your breakfast different on weekends? If so, please list the time you eat and what you eat that is different:

What activities do you do while eating breakfast?

What do you eat and drink for lunch?

What time do you eat lunch?

Where do you usually eat lunch on weekdays?

Is your lunch different on weekends? If so, please list time you eat lunch and what you eat that is different:

What activities do you do while eating lunch?

What do you eat for dinner?

What time do you eat dinner?

Where do you usually eat dinner on weekdays?

Is your dinner different on weekends? If so, please list time you eat dinner and what you eat that is different:

What activities do you do while eating dinner?

What do you eat in the evenings after dinner (i.e. dessert, snacks)?

What do you eat for snacks throughout the day (and when)?

What do you think is the most important thing to tell me about how when and what you eat?

What is your absolute favorite meal of all?

How much water do you typically drink in a day?

Are you a slow, moderate, or fast eater

Do you cook?

What % of your food is home cooked?

Where do you get the rest of your food from?

Do you crave any of the following (please check all that apply):

How many of the items above do you have each day (i.e. 5 cups of coffee):

Are you currently on a specific diet or weight loss program?

The most important thing you believe you should change about your diet to improve your health is:

What are your goals from coaching?

Why are you seeking support at this time?

Is there anything else you want to share?

Thank you for taking the time to complete this form. I will keep this information, as well as all of the work we do together, confidential. I look forward to meeting with you soon!

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Coach Neshama

Intake Form (Long Version)