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
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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
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How often do you typically consume each of the following food groups?
07
Goals + Motivation
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08
Informed Consent + Scope of Practice
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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.