Make Shifts Happen Inc. Intake Forms

Make Shifts Happen Inc.

@make_shifts_happen
Welcome to Performance Nutrition! This type of nutrition coaching uses food, lifestyle and habits to take you to an optimal level of performance. Below you will find a service list, intake forms and next steps to getting started. Please complete the forms to the best of your ability, this information will help us build your Nutrition Strategy in our Initial Nutrition Session. Once you have completed the forms, schedule your first nutrition session at a time that works best using the calendar link at the end of the Intake Forms.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityProvince

Postal
Phone Number
Please enter a valid phone number.
Email
example@example.com
Birth Date

MonthDayYear
Date
Age
Height
Current Weight
Occupation
Were you referred to me ?

YesNo
By whom, I'd like to thank them ?

Performance, Nutrition and Health Goals
Please list the performance, nutrition and health goals that you are looking to achieve
In order of importance
What do you feel are your biggest obstacles in achieving these goals?
How can I help to ensure your success?

Activity
Please describe the type of movement, activity and exercise that you engage in each week (be sure to include duration, and perceived intensity).
Sleep
How many hours of sleep do you get on average?
Do you have trouble falling asleepStaying asleep
Do you wake at any specific times?
What times?
Do you wake feeling rested?

YesNo
Do you take naps?

YesNo

TYPICAL DAY OF EATING

What does a typical day of eating look like for you? Please be as specific as possible, include all food, beverages and supplements. If using photos is easier, there is a section to upload pictures below.
Waketime

Hour Minutes

AM/PM Option
Meal
Beverages:
Supplements:
Time

Hour Minutes

AM/PM Option
Meal
Beverages:
Supplements:
Time

Hour Minutes

AM/PM Option
Meal
Beverages:
Supplements:
Snacks
File Upload

Cancelof
ACKNOWLEDGEMENT AND INFORMED CONSENT
As a client of Make Shifts Happen Inc. I understand that this form of care is based on holistic nutrition and other supportive principles and practices. I also understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or unless it is required by law.

I also confirm that I have the ability to accept or reject this care of my own free will
and choice and that I am not an agent of any private, local, county, provincial, or
federal agency attempting to gather information without so stating. I accept full
responsibility for any fees incurred during care and treatment.
Full Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Print parent/guardian’s name

First NameLast Name
Signature of parent/guardian

Clear

Make Shifts Happen Inc.