NutraPhoria School of Holistic Nutrition: Log in to the site

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
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).
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?
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?
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
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
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Client Intake Form

Lifestyle & Professional Activity

Body Type & Diet History

Daily Habits

Health Concerns

Dietary Profile

Supplements & Medications

Health & Medical Conditions