Coach Neshama
step into your body...step into your life
Short Wellness Intake Form
Today's Date:
-
Month
-
Day
Year
Date
Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Cell phone:
-
Area Code
Phone Number
OK to text?
Yes
No
Age:
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
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7
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13
14
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18
19
20
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25
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27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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2000
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Pronouns
Current Weight:
Weight One Year Ago:
Ideal Weight:
Occupation:
Please rate your stress levels on a scale of 1-10 (10 being high):
1
2
3
4
5
6
7
8
9
10
1=very low stress; 10=very high stress
How would you rate the pace of your life?
Busy, little free time
Moderate
Slow, Relaxed
Do you experience any troubles with digestion? (constipation, diarrhea, IBS, colitis, acid reflux, etc.)
How do you sleep at night?
How much water do you drink per day?
Do you eat when you are bored?
Yes
No
Do you eat when you are stressed?
Yes
No
Would you describe yourself as:
A slow eater
A moderate eater
A fast eater
It depends
Do you have challenges with portion control?
Yes
No
Are you addicted to any of the following
caffeine
sugar
alcohol
cigarettes
Other
How often do you exercise?
What type of exercise do you like best?
Have you tried health / weight loss / nutrition / wellness programs in the past?
Yes
No
If you have tried any programs, what were they, when did you do them and were they successful?
Have you ever received treatment for an eating disorder? Please answer yes/no and explain if yes.
Do you take any medications / supplements, if so please list:
Therapies you are currently doing (i.e. mental health, massage, or other):
Please detail the foods you typically eat for:
Breakfast:
Lunch:
Dinner:
Snacks:
Beverages:
What are your major health concerns?
What would you like to be different 6 months from now?
What is holding you back from being healthier?
Is there anything else that is important to know regarding your health that you have not mentioned?
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