Client Intake Form
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Birthdate
-
Month
-
Day
Year
Date
Age
Height
Feet, Inches
Current Weight
Pounds
Goal Weight
Pounds
Weekly Exercise Information
Explain in detail what type of resistance exercises, cardiovascular or sports activities youperform on average during a 7-day period
Lifestyle & Professional Activity
Occupation
How would you rate the activity level of your profession, or what you do during the day (non-exercise related).
Sedentary
Moderately Active
Active
Very Active
Please choose one
Do you have any hobbies?
If so, please describe
Do you have any children?
Body Type & Diet History
Which of the following statements best describes you?
I can eat practically anything I want and I don’t gain weight.
I find it very hard to gain weight
I can lose or gain weight by adjusting my activity level and eating habits
I find it difficult to lose weight
I can gain weight easily and have to watch what I eat
Please Choose One
What do you feel is your best accountability gauge for your desired progress?
Weight, clothing fitting, etc.
Have you ever been placed on any type of nutritional program in the past? If yes, by whom and what did it consist of?
Results? Challenges?
Daily Habits
What time do you normally wake up?
What time do you normally go to bed at night?
How long does it take you to fall asleep?
If you smoke, how many per day?
If you smoke, how many years have you smoked?
Health Concerns
What are your health concerns?
Describe with symptoms, and durations
How have you dealt with these concerns in the past?
Doctor
Practitioner
Self Care
Dietitian
What other health practitioners are you currently seeing?
List name and specialty
Dietary Profile
Do you have any food allergies?
If yes, please list
Do you have any food sensitivities?
If yes, please list
Have you been tested for food sensitivities?
Yes
No
No, but I would like to
Is there any foods you will not eat under any circumstance?
If yes, please list
Please check off any of the below you use regularly, or often
Candy/Chocolate/Sugar
Splenda/Aspartame
Fried Foods
Packaged Foods
Fast Foods
Lunch Meats
Microwaves
How many cups of water do you drink per day?
How many cups of milk do you drink per day?
How many cups of fruit juice do you drink per day?
How many cups of vegetable juice do you drink per day?
How many cups of alcohol do you drink per week?
How many cups of diet soft drinks do you drink per day?
How many cups of soft drinks do you drink per day?
How many cups of bottled water do you drink per day?
Do you feel that there are restrictions on your diet due to the preference of others - family, roommates, etc?
If yes, please explain
What is a typical day of eating for you?
Please list all meals, snacks, water/other fluid intake
What are your favorite foods?
Do you experience any symptoms if meals are missed?
Please explain
Do you experience any symptoms if meals are missed?
i.e. bloating, gas, fatigue, etc.
Are there foods you avoid because of how they make you feel?
Include the food & symptoms
Supplements & Medications
List any vitamins/supplements/enhancers are you currently taking, including brand nameif possible
Are you on any medications?
If yes, please list
Do you use recreational drugs?
If yes, please list. This includes medicinal marijuana.
Health & Medical Conditions
Check any that apply
Heart Disease
Liver Disease
Celiac
Kidney Disease
Hypoglycemia
Diabetes
Anemia
Autoimmune Disease
Allergies
Hypertension
Asthma
Pain/Inflammmation
Other
Headaches & Dizziness - check any that apply
Fainting
Migraine
Chronic Headache
Neck Stiffness
High Blood Pressure
Low Blood Pressure
Mouth Health - check any that apply frequently:
Bleeding Gums
Bitter Taste in Mouth
Canker Sores
Grind Teeth
Cold Sores
Skin & Hair - check any that apply:
Eczema/Psoriasis
Acne
Hair Loss
Bruise Easily
Dry Flaky Skin
Hives
Itching
Rash
Respiratory & Throat - check any that apply:
Chronic Cough
Recurring Sore Throat
Frequent Colds
Nose Bleeds
Sinus Infections
Winded Easily
Chronic Mucus
Shortness of Breath
Phlegm
Emotions & Memory - check any that apply:
Relaxed/Calm
Foggy Brain
Depressed
Poor Long-term memory
Poor Short-term memory
Poor Concentration
Anxious/Panic Attacks
Easily angered or frustrated
Irritable
Do you experience frequent gas & bloating?
Please explain (i.e. after meals, all the time, etc.)
Do odors bother you?
Yes
No
Have you had periods of binge eating or severe sugar cravings?
Please explain
How do you deal with stress?
i.e. medication, meditation, yoga, supplements, nature walks etc)
Print Name to agree with the above
Submit
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