Health Intake Form

GENERAL INFO

FULL NAME*

PHONE

EMAIL*

Enter Email Confirm Email

AGE

RESIDENCE

City and County

GOALS + OBJECTIVES

Please tell me specifically what you would like to get out of working with me.

CURRENT HEALTH

Please describe your current health issues and challenges. Please include any treatments or medications you are taking including natural supplements or herbs.

Have you ever undergone a detox programme? If yes, please let me know some of the details of the experience and results.

HEALTH AND LIFESTYLE

I eat Organic

Under 10% of my diet
10-30% of my diet
30-60% of my diet
60-80% of my diet
80-100% of my diet

Comfortability in the kitchen. Check all appropriate boxes.

I don't like cooking
I don't mind cooking but don't feel confidant
Usually other people cook for me
I like to cook but don't have time
cooking stresses me out
cooking relaxes me
I cook mainly for my family
I would love to learn more recipes
I like cooking but much prefer eating out

Please add here any additional information you can share about your relationship to cooking, food preparation and how you feel this impacts your diet.

If you live with other people, please describe how this impacts your food preparation/ food shopping and mealtimes. How in control are you of when and what you eat at home?

STRESS: how stressful is your life? What is your workweek like? Do you have a very demanding job? Please tell me everything relevant to STRESS in your life.

SLEEP

SLEEP: Please let me know any additional information about the quality of sleep at this time in your life and how you feel about it.

EXERCISE

never
once in a while, randomly, no regular exercise
1-2 times a week
2-3 times a week
3-4 times a week
4-5 times a week
5-6 times a week
everyday

What type of exercise do you do? Do you have to force yourself to exercise or do you genuinely enjoy it? Please share any relevant info related to exercise.

DIET

Do you follow any particular diet? Check all appropriate

Vegan
Vegetarinan
Pescatarian (fish is the only animal protein)
Other

Please elaborate on your diet, diets you have tried or would like to try, any relevant info.

FOOD SENSITIVITIES

Caffeine
Dairy
Gluten

WHAT DO YOU LIKE TO EAT? Please list 3-5 of your top go-to meals. Favourite things to prepare or eat out.

List any food addictions or challenges you would like to be free of such as sugar, snacking, coffee etc.

Finish this sentence: I feel really good after I eat...(list as many items as you can)

BODY WEIGHT

I am overwight
I am a good size, but would like to be slimmer
I am comfortable with my weight
am underweight and would like to gain some extra pounds

THE PSYCHOLOGY OF EATING

RELATIONSHIP WITH FOOD: Check any appropriate boxes

Space to elaborate on the question above if you need to..

FINAL NOTES

PLEASE LIST ANYTHING ELSE YOU MAY FEEL IS RELEVANT TO THIS PROCESS. Everything here is confidential

The more information I have about where you sit now in your life, and where you would like to go: the greater chance I have of assisting you along that path.

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Health Intake Form

Health Mapping Intake Form

Please take your time here. The more information you share, the easier it will be for me to assist you on your journey.

GENERAL INFO

GOALS + OBJECTIVES

CURRENT HEALTH

HEALTH AND LIFESTYLE

DIET

THE PSYCHOLOGY OF EATING

FINAL NOTES

Health Intake Form

Health Mapping Intake Form

Please take your time here. The more information you share, the easier it will be for me to assist you on your journey.

GENERAL INFO

GOALS + OBJECTIVES

CURRENT HEALTH

HEALTH AND LIFESTYLE

DIET

THE PSYCHOLOGY OF EATING

FINAL NOTES

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