Student Intake Form Intake Form Personal Information Name * Name First First Last Last Birthday * Age Primary Phone Number * Alternate Phone Number Email Address * Occupation * Relationship Status * SingleMarriedWidowedSeparatedDivorced Emergency Contact Name * Emergency Contact Phone Number Health and Wellness Goals What are your primary health and wellness goals/concerns? What would you like to accomplish regarding your health and wellness? Are there any obstacles or challenges that you believe may make it difficult to achieve your health and wellness goals? Family History Mother Father Your Health Do you have regular periods? * Yes No Please list any PMS symptoms Are you taking birth control? Yes No How long have you been taking birth control? Have you had menopause? Yes No Wen did you have menopause? Medications and Supplements Are you currently being treated for a medical condition? Yes No Please list any medications you are taking for this condition. Please list any other medications you are taking. Please list any medications you are taking. Please list any supplements you are currently taking (includes vitamins and probiotics). Please list any allergies or sensitivities. When did you last take oral antibiotics? Food Habits Are you following a special diet? Yes No Please indicate your diet: Vegan Vegetarian Gluten Free Dairy Free Paleo OtherOther How many meals per day do you eat? Do you typically eat breakfast? Yes No Do you eat out at restaurants? Yes No Do you eat prepackaged or frozen foods? No Prepackaged Frozen Both Do you smoke? Yes No How much do you smoke? Do you drink? Yes No How much do you drink? What foods do you crave? Sweet Salty Bread/Pasta Caffeine OtherOther How much water do you drink day? Do you often feel hungry? Yes No What top 5 foods do you eat most frequently? Indicate all that might apply to your current lifestyle and eating habits: Eat Too Much Erratic Eating Patterns Late Night Eating Fast Eater Often Skip Meals Afternoon Fatigue Frequent Colds/Illness Do Not Plan Meals / Eat On The Run Digestion How do you feel after you eat? Gas Bloating Cramping Constipation Diarrhea OtherOther How often do you have a bowel movement? Describe your bowel movements. Lifestyle Describe your typical energy levels. Do you exercise? Yes No How often do you exercise? What type of exercise? Do you feel rested upon waking? Yes No What is your current stress level? Additional Comments or Concerns Informed Consent This nutrition and exercise advice is intended to promote general health and wellness and is not intended to replace medical care. All assessment, suggestions and consultations on the nutrition, diet and exercise are based on the information you have provided. This is not intended to diagnose any disease or ailment. Any activity or program may have inherent risks which may be relative to your state of health and fitness levels, care and skill which you conduct yourself with. You agreed to inquire about any activities with which you are not familiar and provide any information that may limit your participation in the suggested activities. Results and changes in your general health may vary depending on the medical conditions and medications and accuracy in following the suggested guidelines. Never reduce or eliminate physician prescribed medications without the direction of a medical care provider. Date * I agree Slider 50 If you are human, leave this field blank. Submit Start Over
