New Client – Intake form

Name *

First

Last

Email address *

Current Weight (Pounds) *

Height (Feet and Inches) *

Describe any medical conditions you currently have. *

List any medications or supplements that you are currently taking. *

List any food allergies or senstivities. *

What are your top 3 health concerns? *

How many people do you grocery shop for? *

How much (on average) do you usually spend on groceries per week?

Selected Value: 0

How many times per week do you eat food from a restaurant? *

Describe your health, fitness and/or sports performance goals. *

Do you currently follow a specific eating philosophy or type of diet? If yes, describe it. *

Describe a typical breakfast. *

Describe a typical lunch. *

Describe a typical dinner. *

How often do you snack per day and what types of snacks to you typically eat? *

How often do you consume alcohol? *

• Never
• Once in a while
• A few times per month
• A few times per week
• At least once a day

How often do you smoke cigarettes? *

• Never
• Once in a while
• Everyday

Submit