eat simple
Client Intake Form
copyright eat.simple 2015
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Name
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First
Last
Age
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Address
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Email
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Phone Number
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Can I send you text messages to keep in touch as you go through this process?
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Yes
No
Instructions.
Please set aside 15-25 minutes to complete this form. You will not be able to save this information as you go along; you have to complete it in one shot (no pressure!). Once completed, I will be in touch with you in 1-3 business days to schedule a follow-up.
Main Health Concern (MHC). Why are you reaching out to a Nutritionist today?
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Diet:
What kind of animal are you?
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Strictly herbivore
Mostly herbivore
Omnivore
Mostly carnivore
Strictly carnivore
Protein sources: Which ones do you eat? How often do you eat them?
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Whole grains: Which ones do you eat? How often do you eat them?
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Refined carbohydrates (baked goods, pastries, things made from white flour): Which ones do you eat? How often do you eat them?
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Do you try to avoid any certain types of foods?
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What foods do you crave? How often do you give in to the cravings?
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Are you currently taking any supplements? List all.
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What are your favourite foods?
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Describe some of the diets and eating plans you've tried in the past. What worked? What didn't? Please feel free to share as much detail as you can.
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How many times do you eat in a day? Include meals, snacks and treats.
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Generally, how would you describe your current diet. Give me a basic snapshot of what an average day looks like: Breakfast, lunch, dinner, snacks, treats... including times of day, roughly.
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Do you experience any symptoms/feelings/behaviours if meals are missed? Explain.
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How many cups, glasses or servings do you have per day of the following beverages?
Water
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Coffee
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Tea
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Fruit or vegetable juice
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Milk
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Smoothies or shakes
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Pop
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Diet pop
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Alcoholic beverages
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Current Diet Dogma. Select the checkboxes that best describe your current approach to food. (Check all that apply.)
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I try to eat low fat.
I carefully weigh and measure my portions.
I like to prepare a week's worth of meals in advance.
I try to limit my carbohydrate intake.
I am trying to avoid dairy.
I'm not good at meal prep.
I eat on the run quite often.
I have an incredible sweet tooth.
I won't give up my morning cup of coffee.
I know I should be counting calories.
Energy and Mood:
Describe your energy levels throughout the day. Do you have highs and lows? When?
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Stress:
On a scale of 1 to 10, how would you rate your stress level?
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0
1
2
3
4
5
6
7
8
9
10
Describe your main sources of stress.
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How do you react to stress? Do you rely on any coping mechanisms?
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Work:
What do you do for work?
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Do you enjoy your work?
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Yes, usually
Sometimes
No
How many hours a day do you work?
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What type of schedule do you work?
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Regular schedule
Random schedule
Shift work
If you answered 'random schedule,' briefly explain what that means.
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Medical
Current health conditions. Have you been diagnosed with any diseases, and/or are you on any prescribed medications?
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Have you ever been hospitalized, had any major surgery? Please describe.
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Males: Have you experienced any prostate problems? (e.g. frequent urination, discomfort during urination? Please describe.
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Do you have any allergies or sensitivities?
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Describe any pertinent family medical history.
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Females: Are you or could you be pregnant?
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Yes
No
Females: Are you pre-menopausal, peri-menopausal, menopausal or experiencing menopause symptoms? Describe.
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Bowel movements (sorry!):
How often do you have a bowel movement?
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Do you ever have difficult or unusual bowel movements? If so, describe.
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Exercise:
What do you do for exercise? Describe the types of activities, frequency, duration, intensity...
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Sleep:
How many hours of sleep do you get most nights?
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What time do you typically go to bed?
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What time do you typically wake up?
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Describe your sleep quality. Check all that apply.
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I fall asleep easily.
I stay asleep well.
I awaken feeling rested.
I snore.
I have sleep apnea.
I have trouble falling asleep.
My mind wanders which keeps me awake.
I wake up in the night but can get back to sleep usually.
I wake in the night and then can't get back to sleep.
I struggle to wake up when my alarm goes off.
I feel unrested when I wake up.
Accountability:
Please check all that apply.
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I am prepared and excited to embark on this change.
I have the support I need at home/in my life to succeed.
I am prepared to hold myself accountable to the changes prescribed.
I agree to check in with my Nutritionist on a regular basis.
Please share any information you feel is pertinent with regard to your level of commitment through this process. What are your potential barriers? What is going to motivate you to keep going even when it gets a little uncomfortable?
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Communication:
Do I have permission to add you to my email list, and send you nutrition articles and ideas from time to time? I will not be spamming you regularly, I promise.
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Yes!
No thanks.
Do you have any additional notes, comments or questions?
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Acknowledgment
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I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general wellbeing and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.
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