client intake form-adult

Please fill out this form as best as you can. If there are questions you don't understand, or don't want to fill out, we can discuss them during our first meeting.  This form should take you about 10-15 minutes to complete. 

We realize there are a bunch of questions.  Each and everyone is important for us.  The info helps us to get to know your body, which will assist in steering our recommendations. 

Thank you very much for taking the time to answer honestly and completely.
general information
1. date: *
2. date of birth: *
3. contact information *
4. how did you hear about us? *
goals
5. what are your goals for working with a holistic nutritionist? please list in order of priority:
personal information
6. gender
7. age *
8. height *
9. weight *
10. marital status:
11. kids? how many?
12. rate your stress level
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list your stressors: 
13. occupation
14. how many hours in your typical work week:
15. do you travel for work? if yes, how often?
medical information
16. are you taking any medications?
17. if yes, please list name and use:
18. are you taking any supplements?
19. if yes, please list name and use:
20. do you have a lot of aches & pains?
21. if yes, please explain:
22. are you currently seeing a mental health practitioner?
current lifestyle habits
23. please rate your energy level at 9 AM (morning)
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24. please rate your energy level at 12 PM (noon)
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25. please rate your energy level at 4 PM (afternoon)
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26. please rate your energy level at 7 PM (evening)
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27. how do you sleep?
28. bedtime? waking time?
29. do you currently have a regular workout routine? please list
30. do you smoke?
31. do you use recreational drugs? how often?
32. how ready are you to make changes to your diet and lifestyle
health & family history
33. how would you describe your health in general?
34. when was the last time you were on antibiotics? What were they for?
35. do you have KNOWN food allergies or sensitivities?
36. if yes, please explain:
37. do you have KNOWN environmental allergies or sensitivities?
38. if yes, please explain:
health & family history
39. please indicate any of the following that apply to you or anyone in your immediate family:
40. how often do you have bowel movements?
41. if you answered other, please explain
eating habits
42. do you drink coffee? if yes, how much per day?
43. do you drink soda? if yes, how much per day?
44. do you drink water? if yes, how much per day?
45. do you drink alcohol? if yes, how much per day?
46. list your 10 favorite foods:
47. list foods you absolutely WILL NOT eat
48. describe an average breakfast (please be realistic)
49. describe an average lunch
50. describe an average dinner
51. do you eat snacks during the day? if yes, what times?
52. how often do you eat fish?
53. how often do you eat nuts?
54. list the 3 worst foods you eat during an average week
55. list the 3 healthiest foods you eat during an average week
56. are there any foods that you avoid because of the way they make you feel? If yes, please name the foods and symptoms
57. what is your present diet? (AIP, GAPS/SCD, raw, vegan, vegetarian, paleo, refined sugar-free, blood type, gluten-restricted, dairy-restricted, kosher, or no restrictions)?
58. is your present diet working for you?
eating patterns
59. check all that apply:
60. i eat (check all that apply):
61. who generally prepares the meals in your home?
62. bring or buy lunch?
63. how many meals per week do you eat out of the home?
64. how many times per day do you eat on average?
women's issues-ONLY FEMALES ANSWER PLEASE
65. please click all that apply:
Nutrition therapy is not intended as a diagnosis, treatment, prescription, or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care.  This questionnaire is for informational purposes only.
by signing below, I agree that all the information above is true. *