Intake Form

Name*

Email Address*

What is your main health concern?*

Other health issues*

Please list any other health issues you'd like to discuss.

Life Stresses*

On a scale of 1 to 10, with 1 being low and 10 being high, what is your current level of stress?

Main Stressors*

What are your main stressors in life? Finances? Relationships? Self? Work? Others?

Sleep*

On average, how many hours do you sleep? Is it restful?

Smoking & Alcohol*

Do you smoke or drink alcohol? If so please explain.

Water*

How many glasses of water do you drink in a day?

Soda/ Coffee/ Tea*

Do you drink regular soda, diet soda, coffee or tea? If so how many glasses or cups.

Diet*

Do you follow a special diet? Vegan? Vegetarian? Paleo? Keto? Please explain

Allergies & Sensitivities*

Do you have any allergies or food sensitivities?

Family History*

Do you have a family history of diabetes, heart disease, cancer, autoimmune disease or other illness? Please explain.

Gallbladder & Kidney Stones*

Have you had your gallbladder removed or had kidney stones?

Medications & Supplements*

Please list all medications & supplements you are taking

Diet*

Please list what you typically eat for breakfast, lunch, dinner & snacks.

Weight*

What is your current weight? What is your ideal weight?

Waist to Hip Size*

What is your current waist size in inches ? What is your current hip size in inches?

Height*

What is your height?

Exercise*

Do you exercise? If so, how often & what form of exercise?

Occupation*

Do you work? If so, what is your occupation?

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In order to better assist you, kindly complete this quick intake form. Any information provided will be used for the sole purpose of conducting a nutrition consult and will be held in strictest confidence.

*All fields are required. Thank you.