Client Intake

1

What is your name?* This field is required.

First Name

Last Name

2

What is your birth date: year, month, day?* This field is required.

Year/Month/Day

3

What is your gender?* This field is required.

4

What is your email address?* This field is required.

example@example.com

5

What is your phone number?* This field is required.

Area Code

Phone Number

6

How would you prefer me to contact you?* This field is required.

7

How did you hear about my services?* This field is required.

Zen Fitness/Jenn Ricker Client

Naturopathic Doctor referral

Friend/Family

8

Which Naturopathic Doctor referred you? * This field is required.

9

What service are you registering for?In order to help reduce exposure to SARS-CoV-2 all appointments will be held online only. Services that can't be done online are temporarily suspended.

10

Please describe in detail the reason why you need a meal plan and any important details such as dislikes or other issues that may come into play when I create your meal plan.

Meal plans don't require a formal appointment unless there are complex issues that need to be discussed.

11

How tall are you?* This field is required.Please indicate your height in inches.

12

How much do you weigh?* This field is required.Please indicate your weight in pounds

13

Physical Activity Level (Please read closely)

Sedentary:

Sedentary: (Daily PAL range: 1.0 - 1.39): Typical activities of daily living such as gardening (no lifting), household tasks, light activity while sitting, loading/unloading car, mopping, mowing lawn (power mower), etc.

Low Active:

Typical activities of daily living such as gardening (no lifting), household tasks, light activity while sitting, loading/unloading car, mopping, mowing lawn (power mower), etc.
PLUS 30 to 60 minutes of moderate activity daily such as calisthenics (no weight), cycling (leisurely), golf (without cart), swimming (slow), walking 3-4mph, etc.

Active:

Typical activities of daily living such as gardening (no lifting), household tasks, light activity while sitting, loading/unloading car, mopping, mowing lawn (power mower), etc.
PLUS geq60 minutes of moderate activity daily such as calisthenics (no weight), cycling (leisurely), golf (without cart), swimming (slow), walking 3-4mph, etc.

Very Active:

Typical activities of daily living such as gardening (no lifting), household tasks, light activity while sitting, loading/unloading car, mopping, mowing lawn (power mower), etc.
PLUS geq60 minutes of moderate activity daily such as calisthenics (no weight), cycling (leisurely), golf (without cart), swimming (slow), walking 3-4mph, etc.
PLUS additional 60 minutes of vigorous activity such as chopping wood, climbing hills (no load), cycling (moderately), jogging (10-min miles), rope skipping, skating, swimming, tennis (doubles), walking (5 mph) OR 120 minutes of additional moderate activity

14

Based on the description you just read what is your physical activity level?* This field is required.Please be honest this is used to calculate your caloric range.

Sedentary

Low Active

Active

Very Active

15

What service are you registering for?In order to help reduce exposure to SARS-CoV-2 all appointments will be held online only. Services that can't be done online are temporarily suspended.

16

How would you like to have your appointment/sessions?* This field is required.

Online

Over the phone

17

What question(s) would you like addressed during your consult?* This field is required.

18

Health Concerns and or goals: List goals or health imbalances you would like to work on?* This field is required.Please be sure they are relevant to the service or program you have registered for.

19

List all medications, including supplements, sports supplements, herbal remedies, birth control, IUD's....

For Supplements please list brands you are using.

20

If you have any allergies or sensitivities please list them below.

21

Are you filling out this form for a minor or someone who requires a legal guardian?* This field is required.

No

Yes

22

If yes what is your relationship to the minor or individual?* This field is required.

23

What is your name* This field is required.

First Name

Last Name

24

Appointment/Program Terms & Conditions (please read)

All information provided in this form and going forward is confidential and will not be released to anyone.
Individuals seeking Individualized Consulting (in-person or online) will be booked in for two initial appointments. One health & lifestyle assessment and one overview appointment. The fee for both appointments is a packaged fee to be paid at the first appointment.
Individuals seeking “General Consulting” understand that this is a general consult for general nutrition/supplement/botanical remedy questions and will not address disease-specific questions or go into a detailed personalized advice. Those who would like personalized and/or disease-specific consulting should register for the One on One Consulting where a full assessment can be taken.
Body Composition Measurements are not recommended for individuals who have a history of Body Dysmorphic Disorder(s).
Individuals seeking meal plans understand that meal plans are designed for your unique needs and have to be followed in order for them to be effective and to assure all nutritional needs and caloric needs are being met. It is the responsibility of the client to inform Dana of all the details required in this intake form and during any appointments (if an appointment is needed) truthfully and accurately so Dana can properly formulate a meal plan. Should you not implement or fully implement the meal plan Dana Clark/From the Roots Holistic is not liable for any negative health outcomes or lack of benefit. Meal plans are based on your requirements and Dana's formal Academic training.
A formal Consulting & Privacy Agreement will be provided during your first session for you to sign. Online & Phone consult, you will receive a digital copy to sign as well as "Consent to use Electronic Communication" form.
For Health Benefit Claims, you are encouraged to inquire and confirm that you are covered for my services (Registered Nutritional Consultant and/or Certified Natural Health Practitioner) and to submit receipts to your insurance company.
Once your appointment is booked, it is your responsibility to attend this appointment and any future appointments or cancel/reschedule a minimum of 24 hours prior to your appointment. Should you not cancel/reschedule within this time frame you will be charged a $10.00 fee.
All fees are none refundable.

25

By signing this form you are agreeing to all the Appointment/Program Terms & Conditions

Clear

26

How would you like to pay for your appointment or program?* This field is required.

Cash (for in person appointments only, please bring the exact amount)

E-transfer to fromtherootsholistic@gmail.com

Credit card

27

Do you require a formal receipt to submit to any Health Benefits Coverage Plan?* This field is required.

yes

no