Nourished Soul Nutrition Coaching Intake Form

Nutrition Coaching Intake Form

Please be completely honest and take time to consider your responses
Name

First NameLast Name
Email
example@example.com
Home Location
City, State, Country
Phone Number
Please enter a valid phone number.
How did you hear about Nourished Soul?
Birth Date

MonthDayYear
Date
Birth Time

Hour Minutes

AM/PM Option
Birth Place
City, State, Country
Height
Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different? If so, how?
Social - Lifestyle
Relationship Status
Any children?
Please enter their names and ages.
Any pets?
Please enter their names and ages.
Occupation
How would you rate your current stress level?
Have you traveled internationally in the last 6 months? If so, where?
General Health
How would you describe your current health?
What are your main health concerns and goals in seeking nutrition coaching?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is / was your mother’s health?
How is / was your father's health?
What is your ancestry?
What is your blood type?
In a typical day, how many hours do you spend doing the following?
Sleeping
What is the quality of your sleep?

Sleep through the night, wake restedWake up 1-2 times in the night, wake restedWake up throughout the night, wake unrestedInsomnia, difficulty falling/staying asleep- tired throughout the day
Screen Time (phone/tablet/tv)
Working
Self Care (meditation, grounding, praying, painting, singing, etc)
Exercising
How many days a week do you exercise? Practice self-care?
Women's Health

Hormonal

	Never	Rarely	Occasionally	Often	Almost Always
Irregular periods
Hot flashes
Adult acne
Hair loss or thinning
Anxiety
Depression
Mood Swings
Low Libido

How many days is your flow?
How frequent?
Are your moon cycles painful or symptomatic? If so, please explain:
Have you reached or are you approaching menopause? If so, please explain:
What is your birth control history?
Are you pregnant? Is there a possibility you could be?

YesNoMaybe
Are you nursing?

YesNo
Do you experience yeast infections or urinary tract infections? If so, please explain:
Medical
Are you currently under the care of a healthcare provider? If yes, for what condition?
Do you have any diagnosed medical conditions (e.g., IBS, IBD, Crohn’s, Celiac Disease, SIBO)?
Are you currently working with any holistic healers, helpers, or alternative therapies, and what treatments have been beneficial for you in the past, even if you’re not currently using them?
Are you currently taking any pharmaceutical medications, drugs, supplements and / or any herbal remedies? Please list along with the dosage.
Any allergies or sensitivities to medications or supplements?
Any inflammation, pain, stiffness, or swelling?
Gut Health
How would you describe your current digestive health?
What are your primary goals for seeking help with your gut health?

Digestion

	Never	Rarely	Occasionally	Often	Almost Always
Excess belching after meals
Acid reflux / heartburn
Constipation
Diarrhea
Excessive Gas
Nausea
Hemorrhoids
Abdominal pain or cramping
Use of laxatives
Bloating
Mucus in stool
Blood in stool

How often do you experience these symptoms?
Have you identified any specific foods that trigger your symptoms? Do you have any known food allergies or intolerances?
Have you undergone any previous tests related to gut health (e.g., colonoscopy, stool test, food sensitivity test)? If yes, what were the results?
Have you done any cleanses, fasting, parasite or colon cleanses in the past? Which ones and how recently/often?
Have you tried any treatments or dietary changes for your gut health? What were they, and did they help?
Have you noticed any correlation between your gut symptoms and your mental state?
Are there any current life stressors affecting your health?
Do you experience frequent colds, sinus infections, or other signs of a weakened immune system?
Have you had food poisoning or stomach infections in the past year?
Have you taken antibiotics, antifungals, or steroids recently? If yes, when?
Bowel Movements
How often do you have a bowel movement?
What is the consistency of your stool according to the Bristol Stool Chart?
Do you feel you completely empty your bowels when you go?
Have you noticed any changes in the color, texture, or odor of your stool?
Food
How would you describe your current diet?
How is your relationship to food? Do you find yourself eating emotionally, using food for comfort or stress relief? Do you eat mindlessly or primarily for energy, without considering how the food nourishes your body? Are you aware of how your food choices impact your overall well-being?
History with Eating Disorders

YesNo
If yes, please explain when, for how long, if you are currently struggling with this, how severe, and how you overcame it.
Do you cook? What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
What foods did you eat often as a child?
What foods do you typically eat these days?
Do you eat fermented foods (e.g., yogurt, kefir, sauerkraut, kimchi)? If yes, how often?
How often do you consume processed foods, fast foods, or sugary snacks?
Do you consume a lot of artificial sweeteners, soda, or caffeine?
Do you regularly drink alcohol? How many drinks per week? Please be honest (no judgement)
Do you smoke cigarettes? If yes, how often? Do you partake in recreational drugs or have any major addictions?
How much water do you drink daily?
Do you regularly have drinks with ice in them? How often?
What is the most important thing you should change about your diet to improve your health?
Additional Comments
Is there anything else you would like to share?
Nutrition Coaching Acknowledgment and Consent Form
Welcome to Nourished Soul Nutrition Coaching! Before we embark on this journey together, please review the following key points to ensure you understand our services:

Acknowledgment of Complementary Therapy: I understand that nutrition coaching is a complementary service and not a substitute for medical treatment, diagnosis, or professional healthcare. I will continue to seek medical advice and treatment from my healthcare providers as needed.

Consent to Receive Nutrition Coaching: I consent to participate in nutrition coaching sessions, recognizing that this process involves guidance on diet, lifestyle, and wellness practices. I am aware that recommendations are based on general health principles and are not personalized medical advice. My participation is voluntary, and I can choose to withdraw at any time.

Confidentiality Agreement: I understand that all information shared during nutrition coaching sessions will be kept confidential. The coach will not disclose any personal details without my consent unless required by law.

Release of Liability: I release the coach from any liability or responsibility for any outcomes, results, or changes in my health that may occur during or after the coaching process. I acknowledge that I am participating voluntarily and am fully responsible for my own health decisions.
By signing below, I confirm that I have read, understood, and agree to the above statements.

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All of the facts in this form are true to the best of my knowledge and beliefs

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Nutrition Coaching Intake Form

Social - Lifestyle

General Health

In a typical day, how many hours do you spend doing the following?

Women's Health

Medical

Gut Health

Bowel Movements

Food

Additional Comments

Nutrition Coaching Acknowledgment and Consent Form