Intake Form

Name

Email address

What are your health, lifestyle, and dietary goals?

What types of changes to your health are you hoping to achieve by working towards these goals? (ex. weight loss/body composition changes, better body image, more energy, clearer skin, better overall health, healthier lifestyle, being more active, more positive attitude, etc)

Why are these changes important to you? How will your life improve because of them?

What interventions have you taken, if any, to address your health concerns? Include details about treatments, programs, diets, supplements, drugs etc.

What do you do for work and what is your schedule like?

If yes, please list them below and what you take them for

If you regularly have low energy (below 7), please elaborate on why you think that is and how it affects your everyday life

What are the sources of your stress?

What relaxation techniques do you find helpful to manage stress?

How often have you had Antibiotics in the past?

Do you have any allergies/sensitivities to food, environment or products?

Do you smoke/vape?

If yes, please elaborate

Tell me about your sleep patterns (when do you go to bed and wake up, do you sleep well, do you feel rested in the morning, do you use products to help you sleep, etc.)

Please expand on why or why not

Describe your typical breakfast

Describe your typical lunch

Describe your typical dinner

Describe your typical snacks

How often do you eat out?

What kinds of foods do you eat when you eat out?

Approximately how much water do you drink every day?

What other beverages do you regularly consume?

How often do you drink alcohol?

What are your favourite healthy foods to eat?

What are your favourite meals to eat?

What are your least favourite foods?

What are some of the diet and lifestyle changes you know you need to make in order to see progress?

What is your motivation for wanting to make diet and lifestyle changes?

What excites you about making these changes?

Is there anything that scares or intimidates you about making these changes?

Is there anything else you'd like to share that hasn't been covered above or you feel is relevant for me to know?

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