Nutrition Intake Form
Personal Information
Start Date
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Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Health Concerns
What are your main health concerns?
What are your goals for the 3 months working together?
Do you have any medical diagnosis or ones you are concerned you have?
What have you done in the past that has helped you feel better?
What have you tried in the past that didn't work?
Do you have a family history you're concerned about?
Do you have anxiety or depression?
How does that affect your health?
List any vitamins or supplements you take.
How are your menstrual cycles? Do you cycle regularly? Do you have PMS symptoms?
Are you on birth control? How long and what form?
Are you trying to conceive or do you plan to soon?
How many children do you have? Ages?
Have you had any miscarriages?
Nutrition
What is your favorite food(s)?
Do you have a eating disorder or distorted relationship with food?
Do you avoid certain food because of binge eating or overeating? What foods are those?
Do you have any food allergies?
Do you have any food restrictions or dietary preferences?
Have you ever done a Detox or intermittent fasting?
How is your mental clarity/memory?
How often and how much do you drink caffeine?
Do you drink alcohol? How much/ how often?
Do you cook a home?
How often do you eat out? Do you eat fast food?
Do you have a food budget?
Lifestyle
What do you do for work?
How long is your commute? Daily driving?
How active are you during the day?
Do you work out? How often and for how long?
What type of workouts do you do?
What are your sleep habits? What time do you go to bed/what time do you wake up? How many hours of sleep do you get nightly?
Do you have a hard time falling asleep or staying asleep?
Anything else?
We are all bio-individuals, so please add anything else you would like me to know about you and your health.
Is there anything else you would like me to know before we chat?
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