Women's Intake Form
Print Women's Intake Form
Women's Intake Form
How often do you check your email?
Best phone number to reach you?
Date and place of birth
Weight 6 mo. ago?
Weight one year ago?
Would you like your weight to be different? If so, what?
Hours a work per week?
Please list your main health concerns:
How often does it (your health complaint) bother you?
What have you tried to far that has not worked?
Is there anything getting in the way? (bad habits, poor relationship, job stress etc)
At what point in your life did you feel best?
On a scale of 1-10, how motivated are you to get healthy and reach your goals?
What is the #1 Goal you would like to accomplish in the next 6 months?
What is the 2nd most important goal you would like to accomplish in the next 6 months?
What is the 3rd most important goal you would like to accomplish in the next 6 months?
Why would you like to achieve these goals?
Any serious illnesses/hospitalizations/injuries?
How is/was the health of your father?
How is/was the health of your mother?
What is your ancestry?
What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night? if yes, why?
Are your periods regular?
How many days is your flow?
Painful or symptomatic? Please explain:
Reached or approaching menopause? Please explain:
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain:
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas? Please explain:
Allergies or sensitivities? Please explain:
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list:
What role does sports and exercise play in your life?
What foods did you eat often as a child? Breakfast - Lunch - Snacks - Liquids
What’s your food like these days? Breakfast - Lunch - Snacks - Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you crave sugar, coffee, cigarettes, or have any major addictions?