Health Intake

Thank you for taking the time to fill this out prior to our session. Please note that your information will be kept confidential.
(* = required fields)

Name: *

Date:

Address: *

City: *

State: *

Phone: *

Email: *

Birthdate:

How did you hear about us?

Would you like your weight to be different?  Yes No

If so, explain?

Relationship status:  Single Married

Children:

Pets:

Occupation:

Hours of work per week:

What is your main health concern?

What have you done in the past to work on this health condition?

What has proven effective?

What is your current diet like?

Do you crave sugar, coffee, or have any major addictions?

Are you taking any supplements or medications? Please list:

Do you experience indigestion/constipation/diarrhea/gas? If so, please explain:

Do you sleep well?  Yes No
How many hours?
Do you wake up at night?  Yes No

What role does sports and exercise play in your life?

What percentage of your food is home cooked?

Do you cook?  Yes No
Where do you get the rest from?

Where would you like your health to be 4-6 months from now?

What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle?

What do you hope to get out of our session?

What is one thing you love about your life?

Anything else you want to share?