Mind Body Nutrition Intake Form
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Texas
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Vermont
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State
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Emergency Contact
How do you prefer to schedule our sessions?
In Person
Phone
Skype
Thanks for letting me be a part of your health journey! So, if you could waive your magic wand and get whatever you want in our work together, what would that be?
Are you taking any medications? If so, please list.
Are you taking any supplements? If so, please list.
How long have you dieted for?
When did you first start dieting in life
What is your height?
How much do you weigh right now?
How much did you weigh 6 months ago?
How much did you weigh 1 year ago?
How much do you want to weigh?
When was the last time you weighed this amount
Are you on any kind of weight loss program right now?
How have you tried to lose weight in the past?
What diet(s) has been most successful?
What do you honestly think will help you lose weight and keep it off
Did your weight gain occur at a specific time in your life?
What else was going on at time you gained weight? (work, relationship, divorce, death in family, kids, health issue, break-up, finances…)
Why do you want to lose weight?
How is the weight situation in your family – parents, siblings? Do they or did they have weight issues? Diabetes? Digestion issues?
Relationship Status
Please Select
Single
Married
In a relationship
Separated
Divorced
Widowed
Do you have kids?
Please Select
Yes
No
Want Kids
If you have kids, what are their ages and names?
What do you do for work?
Any other symptoms or health challenges that I should know about?
Digestion
Low Energy
Mood Swings
Brain Fog
Food Allergies/Sensitivities
Constipatation
Diarrhea
Gas
Skin Issues (ie. Acne, Eczema etc)
Pain, Stiffness or Swelling in your Body/Joints
Headaches
Acid Reflux
Poor Quality Hair/Nails
Dizziness
Chronic Sinus Congestion or Chronic Runny Nose
Sensitivity to scents (ie. perfumes, chemicals)
Blood Pressure
Please list your food allergies/sensitivities
Are you under a doctor’s care?
Yes
No
Have you had any thyroid issues/tests?
Yes
No
Diabetes/insulin resistance tests?
Yes
No
Are you taking any supplements for weight loss?
Yes
No
Have you been treated for any conditions with steroid hormones?
Yes
No
Have you had chemotherapy before?
Yes
No
What are your main health concerns?
If female, do you have...?
Breast Implants
IUD
Other Implant
Women- Do you frequently have yeast/urinary tract infections?
Yes
No
Women...Have you reached menopause
Please Select
I'm not in menopause
I'm near menopause
I'm in menopause
I've already been through menopause
Have you had any serious illnesses, hospitalizations or injuries?
Have you ever experienced a traumatic event in your life?
Are you currently working with any therapists, holistic practitioners or physicians?
At what point in your life did you feel your best?
Do you sleep well at night?
Yes
Sleep? What sleep??
Most of the time
Some of the time
How many hours a night do you usually sleep?
What do you do for exercise/movement?
What would your ideal relationship with food look like?
What would your ideal relationship with your body look like?
How is your hunger level at Mid Morning?
Please Select
Not hungry
Hungry
Ravenous
Afternoon?
Please Select
Not hungry
Hungry
Ravenous
Dinner time?
Please Select
Not hungry
Hungry
Ravenous
Do you have any food cravings?
Sugar
Caffeine
Chocolate
Coffee
Soda
Other caffeinated beverages
Diet soda
Breads/pasteries
Salty foods
Crunchy foods (ie. popcorn, pretzels, chips etc
How many of the above do you have a day? (ie. Sodas, cups of coffee etc)
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