Health Intake Form

First name

Last name

Phone

Preferred Method of Contact

Text

Call

Birthday

Month

Day

Year

Address

Emergency Contact Information

Name

Relationship

Phone

Please answer questions below with respect of where you are at today.

List any diagnoses, medications, conditions, or injuries that would like me to be aware of.

List any beliefs, identities, cultures, lifestyle, values, or anything you would like me to be aware of that may impact your health and wellness.

How much sleep are you getting on an average night?

How much physical activity/movement do you include each week?

What does an average day look like regarding meals, snacks, water intake, etc.? Give a brief idea what you are eating and how much, if unsure give an estimate.

Water Intake

Breakfast

Lunch

Snacks

More details, if able...

Fruits and Vegetables

Sugar

Protein

Carbs

Dairy

Grains

Supplements, vitamins, etc

If able and comfortable please share any of the following information.

(I cannot interpret lab information but I can assist in any changes you are looking to make.)

Total Cholesterol, HDL, & LDL

Blood Pressure

AIC

Weight & BMI

Please rate each category below on a scale of 1-10. 1 being low and 10 being high. All answers are based on where you are at today. There is now wrong answer. Insert the number 1-10 in the box below each category.

Movement/Physical Health

Stress Coping

Sleep

Healthy Eating/Nutrition

Relationships

Social Connection/Community

Environment

Finances

Career

Spirituality and/or Religion

Growth/Learning or Education

Fun/Leisure

Self-Care

Healthcare Adherence (Regular visits, prescriptions, etc)

How did it feel to feel out this intake form?

What are your desires and/or goals for your overall health and wellness?