Evexia Science — Client Intake Form
Client Intake Form
■ Confidential Health Record
01
Personal Information
Select...
Male
Female
Intersex
Prefer not to say
Phone call
Phone call
Text message
Email
02
Body Measurements + Lifestyle

Physical Activity

Sleep + Stress
Good
Excellent
Good
Fair
Poor
03
Health + Medical History
Family History

Personal Medical + Digestive History
No recent labs
No recent labs
Yes — within last 6 months
Yes — within last year
Older than 1 year
04
Medications + Supplements
05
Dietary Patterns + Restrictions

Eating Behaviors
3
1–2
3
4–5
6+
Highly variable
Occasionally
Rarely / never
Occasionally
Most meals
Almost all meals
1–2×/week
Rarely (< 1×/wk)
1–2×/week
3–4×/week
Daily or more
None
None
Occasional (< 1 drink/wk)
1–7 drinks/week
8–14 drinks/week
15+ drinks/week
None
None
< 50 mg
50–100 mg
100–200 mg
200–300 mg
300–400 mg
> 400 mg
$200–$400
< $200
$200–$400
$400–$600
$600–$800
> $800
Prefer not to say
Intermediate
Beginner
Intermediate
Advanced
06
Food Group Frequency

How often do you typically consume each of the following food groups?

07
Goals + Motivation
08
Informed Consent + Scope of Practice
Client Signature
Date

Thank You.

Your intake form has been received. We'll review it before your first appointment and look forward to working with you.