Student Intake Form

Intake Form

Personal Information


Health and Wellness Goals

Family History

Your Health

Do you have regular periods?
Are you taking birth control?
Have you had menopause?

Medications and Supplements

Are you currently being treated for a medical condition?

Food Habits

Are you following a special diet?
Please indicate your diet:
Do you typically eat breakfast?
Do you eat out at restaurants?
Do you eat prepackaged or frozen foods?
Do you smoke?
Do you drink?
What foods do you crave?
Do you often feel hungry?
Indicate all that might apply to your current lifestyle and eating habits:


How do you feel after you eat?


Do you exercise?
Do you feel rested upon waking?

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.

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