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.

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.

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 work week like? Do you have a very demanding job? Please tell me everything relevant to STRESS in your life.

SLEEP. On average, how much sleep do you get a night?

SLEEP: Please let me know about the quality of your sleep. Do you wake up at night? Do you fall asleep easily? Do you feel rested when you wake up? Please share anything you think is relevant about your relationship with sleep.

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.

MEDITATION. Do you have a meditation practice?

Never
Tired it and don't like it
I find it valuable but i'm Irregular
2-3 times a week
3-4 times a week
Everyday
5-6 times a week
everyday

Please share any spiritual or body-mind practices you have.

DIET

TIME ALLOWANCE

How much free time do you have?

DIET

Do you follow any particular diet? Check all appropriate

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

DIET: Please elaborate on your diet in general. Do you feel good about this area of your life? Do you feel big improvements could be made here? Please share any relevant information about your diet in general.

SUPPLEMENTS. Please list all supplements or herbal medicine you take.

FOOD SENSITIVITIES OR ALLERGIES.

Caffeine
Dairy
Gluten
Wheat
Other

If you would like to elaborate on any of the food sensitivities or allergies please do so here.

WHAT DO YOU LIKE TO EAT? Please list 3-5 of your top go-to foods or meals. Favourite tastes, things that you have always loved, good or 'bad'.

List any food addictions or challenges you would like to be free of such as sugar, snacking, overeating, skipping meals, 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

WATER INTAKE. Do you drink plenty of water? Is staying hydrated an issue for you?

I am chronically dehydrated
I drink water, but have to force it down as I'm rarely thirsty
I only drink herbal teas for water intake
I drink water all day long
I am very conscience about how much water I drink and make sure to drink 2 litres a day at least

ELIMINATION

NUMBER 2. Please describe how well you are eliminating. Choose all relevant options.

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

Quantum Nutrition Intake

GENERAL INFO

GOALS + OBJECTIVES

CURRENT HEALTH

HEALTH AND LIFESTYLE

DIET

TIME ALLOWANCE

DIET

ELIMINATION

FINAL NOTES

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