Wellness Coaching
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1003 Diamond Avenue
South Pasadena, CA, 91030
(626) 354-5319
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Wellness Coaching
Nutrition
TRAINING
Retreats
BLOG ARCHIVES
New Client Intake Form II
New Client Information
PLEASE COMPLETE THE FOLLOWING INTAKE FORM:
Name
*
First Name
Last Name
Email Address
*
Phone Number
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(This will forever remain private and secure)
Height
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Select
4' 0"
4' 1"
4' 2"
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4' 5"
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5' 0"
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5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
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6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7'
Age
*
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Birthday
How did you hear about us?
Why are you here? What is your motivation/drive?
Have you ever worked with a nutritionist?
*
Select
Yes
No
List the "diets" you've tried (if any):
BACKGROUND
When was your last physical with a lab panel?
What are your current medical concerns?
*
Please note any chronic pain, digestion issues, headaches, high blood pressure, pre-diabetes, etc.
Current supplements/medications? Please include dosages.
Please include dosages. If you are on birth control, please note what type.
Do you struggle with constipation or loose stool?
*
Are you bloated and/or gassy regularly?
Do either of your biological parents have a history of Type 2 diabetes, addiction, heart disease, high blood pressure, or cancer?
Have you ever struggled with anxiety or depression? For men, depression can manifest in bouts of rage, persistent irritability, and/or shutting down emotionally.
Please note any bouts of situational depression or anxiety.
Do you have a history of restrictive eating, disordered eating, anorexia, bulimia, or binge eating?
*
Select
Yes
No
Please describe any wellness services you frequent: chiropractic services, acupuncture, holistic practitioners, etc.
Activity/movement
What physical activities do you enjoy?
Please note any sports or activities you enjoy.
Have you had any major physical injuries?
Please note any broken bones, surgeries, torn tendons, etc.
Do you currently strength train? Please explain.
How often do you currently exercise? What type(s) of exercise?
Body image
Do you feel good about yourself/confidant most of the time? Please explain.
Do you often compare yourself to others?
Name at least three character strengths that you posess::
How often do you use social media?
Nutrition/Lifestyle
Do you use food/drink as stress relief, reward, etc. ?
What is your food value (vegetarian, paleo, vegan, etc)?
*
Do you have any food allergies or aversions?
*
How much caffeine do you drink daily? Are you sensitive to caffeine intake?
Do you drink alcohol or use recreational drugs? If so- how often?
How much water do you consume each day? Do you take electrolytes?
How many cups of vegetables do you eat per day (on average)?
Do you have a consistent wake time and/or bedtime? Please explain:
How often do you cook? Do you enjoy cooking?
Please check the following kitchen items you own/use:
Blender
Slow Cooker/Crock Pot
Oven
Microwave
Skillet
Spiralizer
Quality Knife Set
Please check the following skills you have practiced:
Chopping and storing veggies for the week
Roasting veggies
Freezing meals
Cooking 1-2 large meals on the weekend for the week
Creating a meal plan for the week
Creating a shopping list
Carrying portable non-perishable snacks
Ordering from a menu but asking for amendments/substitutions
How often you eat seated at a table without distractions (TV, phone, etc.)?
*
Do you eat quickly?
Do you often eat until you are uncomfortable or do you stop eating when you are 80% full?
Do you meditate or practice yoga?
What is your social support system like? Who lives with you? What activities do you do with friends?
What activities do you enjoy doing at home?
What is your "night routine" like? How many hours of sleep do you get a night?
Lifestyle: what are two lifestyle habits that you want to improve?
Have you ever used a food tracking app? Which one(s)?
Thank you for taking the time to fill out this intake form. If you have any questions before your appointment, please let us know!
Thank you
