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Nutrition & Fitness Consultation Client Intake Form
In order to help us provide you with the most effective and personalized plan for you, please answer all the questions honestly and with as much detail as possible.
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Name
*
Email
*
Email
Confirm Email
Date of birth
*
Age
*
Sex
*
Male
Female
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Are you currently receiving treatment at our office?
*
Yes
No
What are the treatments for and by whom?
*
How did you hear about this particular program?
*
What motivated you to want to try this program?
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What are some of the main goals you would like to achieve in this program?
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Lose weight
More energy
Increase athletic performance
More restful sleep
Relieve chronic pain
Gain strength/mobility
Improve diet
Meal planning/prep
Improve overall health
Other
Mark all that apply.
Other
*
If your main goal is to lose weight what is the MOST important reason to you?
*
Feel better
Look better
Family history prevention
More energy
Improve health condition
M.D. recommended
Try something new
Other
Mark all that apply.
Other (copy)
*
What are some other ways you have previously tried to reach your own nutrition and fitness goals? Includes diet or exercise programs, supplements, books, etc.
*
How many hours of sleep per night do you currently get?
*
Do you currently have an exercise routine?
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Yes
No
How many times a week do you exercise?
*
Do you have a favorite type of exercise?
*
Walking
Running
Strength Training
Yoga
Swimming
Martial Arts
Hiking
Cycling
Group Classes
Select up to three (3).
How often do you prepare meals at home?
*
per week.
How often do you eat out/pick meals up?
*
per week.
What types of fruits and vegetables do you normally eat?
*
Fresh
Frozen
Canned
How often do you consume fruits/vegetables?
*
Daily
3-4x week
2-4x month
Rarely
Do you consume animal protein?
*
Yes
No
What varieties of protein are part of your normal diet?
*
Fish
Chicken
Beef
Dairy
Plant Protein
Mark all that apply.
Are there any specific improvements or changes you would like to make in your current diet?
*
Which program are you interested in?
*
Restoration
Transformation
Total
$ 0.00
How would you like to pay?
*
Credit/Debit Card
PayPal
Credit/Debit Card
*
Card
Name on Card
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Phone
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