Intake Form Personal Information Name * Age Email * Phone Number Address Main Health Goals Please describe the health and lifestyle transformation you desire to achieve during this Health Coaching relationship. Describe the patterns you seem to fall into again and again with regard to making health and lifestyle transformation. What other diets, programs, or approaches have you tried in the past, and what were your results? Describe your beliefs about your ability to transform your own health. What support do you have at home, at work, and in your life to succeed in this program? What barriers can you perceive or predict? What aspects of your home, work, and life have previously detracted from your ability to succeed? What hobbies, interests, and passions do you partake in? Please share any information you feel is pertinent with regard to your level of commitment through this process. What is going to motivate you to keep going even when it gets a little uncomfortable? Nutrition Diet snapshot. Generally, how would you describe your current diet? Provide a basic snapshot of what an average day looks like: Breakfast, lunch, dinner, snacks, treat and beverages. Please include times of day as well. Protein. Which protein sources do you eat? How often do you eat them? Whole grains. What types of whole grains do you eat? How often do you consume them? Refined carbohydrates. What types of refined carbohydrate snacks (like candies, crackers, cookies, pastries, baked goods) do you eat? How often do you eat them? What are your favorite foods? Do you try to avoid any certain types of foods? What foods do you crave? How often do you give in to the cravings? Do you experience any symptoms/feelings/behaviors if meals are missed? Explain. Are you currently taking any nutritional supplements? List all. Beverages. How many glasses or servings of the following do you have in a day, week, or month? Please provide quantity and frequency. Water Coffee - How do you take your coffee? Tea - How do you take your tea? Fruit or vegetable juice; kombucha - Please provide details around your consumption of juices: type, when, why? Milk (dairy and non-dairy) - Please provide details around your dairy and non-dairy milk usage: type, when, why? Smoothies or shakes - Please provide details: smoothie/shake ingredients; when and why you consume smoothies or shakes, etc. Soda and Diet Soda Alcoholic beverages - Please provide details: What type of alcoholic drink, when, why? Energy and Mood Describe your energy levels throughout the day. Do you have highs and lows? When? On a scale of 1 to 10, how would you rate your stress level? Select 1 2 3 4 5 6 7 8 9 10 Describe your sources of stress. How do you react to stress? Do you rely on any coping mechanisms? Sleep Sleep quality. Check all that apply: I fall asleep easily. I stay asleep well. I wake up feeling rested. I snore. I have sleep apnea. I have trouble falling asleep. My mind wanders which keeps me awake. I wake up in the night but can get back to sleep usually. I wake in the night and then can't get back to sleep. I struggle to wake up when my alarm goes off. I feel unrested when I wake up. Sleep quantity. How many hours of sleep do you get most nights? What time do you typically go to bed? What time do you typically wake up? What else should I know about your sleep habits, patterns, quantity, and quality? Exercise & Movement Non-exercise movement. Non-exercise movement can include things like the walking you do throughout your day, moving around, chores, manual/physical tasks, fidgeting, etc. Please describe your daily non-exercise movement. Exercise. Exercise is described as the deliberate attempts you make to move your body; your workouts, weight lifting sessions, yoga or fitness classes, and taking long walks. What do you do for exercise? Describe the types of activities, frequency, duration, intensity, etc. Are you a competitive athlete? If so, describe your sport. What are your fitness goals? Check all that apply: General health Muscle mass gain Fat loss “Looking Good Naked" Improved physical performance Improved bone density Improved cardiorespiratory health Preventing age-related muscle loss Stress management Improved mood Other If you checked Other, please describe: Do you have any physical limitations in terms of your ability to partake in an exercise program? Bowel Health How often do you have a bowel movement? Do you ever have difficult or unusual bowel movements? If so, describe. Work and Life What do you do for work? Do you usually enjoy your work? How many hours a day do you work? What type of schedule do you work? Check all that apply: Regular schedule Random schedule Shift work If you answered 'random schedule,' briefly explain what that means. What is your family and home-life situation? Married? Children? Taking care of elderly parents? Please describe with as much detail as you feel comfortable sharing. Medical History Current health conditions. Have you been diagnosed with any diseases, and/or are you on any prescribed medications? Have you ever been hospitalized, had any major surgery? Please describe. Do you have any allergies or sensitivities? If Yes, please describe. Do you smoke? Do you partake in recreational drugs? If Yes, which ones, how often, and why? Describe any pertinent family medical history. Females: Are you or could you be pregnant? Females: Are you pre-menopausal, peri-menopausal, menopausal or experiencing menopause symptoms? Describe. Conclusion Do you have any additional notes, comments or questions? Acknowledgement Required: * I understand that the services provided are at all times restricted to consultation on the subject of health matters intended for general wellbeing and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. 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