Intake Form

Thank you for taking the time to fill out the following questions as these help me prepare for our first call together!

All of your information will be kept confidential.

First & Last Name

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1. What is your main health concern?

2. What have you done in the past to work on this health condition? (include both alternative and traditional modalities.)

3. What has proven effective?

4. What is your current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.

5. Are you taking any supplements? Please list what you take and what it is for.

6. What would you like your health to be 30 days from now? How about 90 days from now? How would you feel if you got this result?

7. What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle?

8. What do you hope to get out of our time together?

9. What are 5 things you LOVE about your life?