Intake

Address *

Line 1

Line 2

City

State

Zip Code

Country

Sex *

Male Female Prefer not to say

What medical concerns (e.g., recent surgery, pregnancy), if any, do you have at the present time? *

Do you use tobacco in any way? *

Yes No

Did you recently stop smoking? *

Yes No

Do you enjoy physical activity? *

Yes No

List any food allergies or intolerances *

List any prescribed, over-the-counter, herbal, recreational drugs, or vitamin/mineral supplements you take. *

How often do you work out per week? *

Do you work out more than once a day? *

Yes No

Do you follow a special dietary plan, such as, low cholesterol, kosher, vegetarian? *

Have you ever followed a special diet? *

Yes No

Do you have any problems purchasing foods that you want to buy? *

Yes No

Are there certain foods that you do not eat? *

Yes No

Do you eat at regular times each day? *

Yes No

What foods do you particularly like? *

How much water do you drink PER day? *

Do you drink alcohol? *

Yes No

What change would you like to make? *

Please add any additional information you feel may be relevant to understanding your nutritional health and overall lifestyle. *

In order to tailor your counseling experience to your needs, it helps to know your expectations. Check one of the following to indicate the amount of structure you would need: *

Tell me exactly what to eat for all my meals and snacks. I want a detailed food plan. I want a lot of structure but freedom to select foods. I want some structure and freedom to select foods. I don’t want a diet. I just want to eat better. Other

Highest level of formal education? *

How many people in your household? *

Present marital status? *

Who prepares most of the meals in your home? *

How often do you eat out per week? *

If you eat out, where? *

Have you made any food changes in your life you feel good about? *

Yes No

Who could support & encourage you to make these changes? *

INTAKE FORM

Personal Intake Form

CONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.

Who we are

What we do

How to contact

Want Us to Contact You?

INTAKE FORM

Personal Intake FormCONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.

Who we are

What we do

How to contact

Want Us to Contact You?

Personal Intake Form

CONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.