Intake Form

Part 1 - Getting to Know You

Name (First Last)

What is motivating you to make a dietary and/or lifestyle change?

What do you hope to accomplish with this program? (Weight loss, better sleep, gain muscle, eliminate diabetes, better sex, improve skin health, improve athletics, increase fertility, stay agile for kids/grandkids, reduce illness, reduce joint pain,...)

Do you have a timeline for reaching your goals?

Have you tried reaching your goals before? What past experiences might positively or negatively influence your thoughts and emotions surrounding your goals? Are there any strategies that worked or didn't work?

What obstacles do you foresee getting in the way of reaching your goals? How might we be able to support you in overcoming these?

Describe what you consider a healthy breakfast & healthy dinner. Roughly what percentage of your meals do you consider 'healthy'?

How much do you currently spend per month on food, supplements, & restaurants?

How are your cooking skills?

I burn frozen pizza

I make a mean hamburger

Give me instructions and I'll whip up a masterpiece

Recipes are merely inspirational suggestions - I'm a culinary artist

How much time per recipe do have to cook or meal prep?

Do you have any dietary restrictions or food allergies, any food preference aversions, or any self-imposed dietary restrictions (religious, moral, environmental...)

Do you have any environmental allergies?

What, if any, is your current exercise routine?

Are you interested in a dedicated workout or training plan for general health or a specific athletic goal?

Yes

List all medications you take (prescriptions and over the counter). 'N/A' if none. Please list the reason for the medication, if comfortable sharing.

Note: We will not give any direct recommendations about medication. We may share possible side effects and concerns about medications and encourage you to discuss with your doctor.

List all supplements you take regularly. 'N/A' if none.

Is there anything else you'd like to share to help us get to know you?