Intake Form | My Site

First name

Last name

Birthday

Month

Day

Year

Gender

Female

Male

Height(feet)

Height(inches)

Weight(lbs)

Address

Phone

Email

Occupation

Marital Status

Married

Cohabitating

Single

Other

My baseline physical structure can be best described as:

Slim and slender, lightweight, hard time gaining weight but easy time losing it, prominent joints that often crack

Medium built, well developed muscles, average weight, weight is not easily gained, soft/loose joints

Well built, stocky, easy time gaining weight but hard time losing it, broad shoulders and chest, large/deep-seated joints

My skin is:

Dry, cold, rough, cracked, thin

Warm, moist, pink, with freckles, acne or moles/birthmarks

Thick, moist, cold, soft/smooth

My lips are:

Thin, dry, cracked

Soft, curved, soft

Thick, large, oily, smooth, firm

My hair is:

Thin, dry, straight

Moderate, fine, brown/red/blonde, receding hairline

Thick, oily, black, wavy

My speech is:

Quick, erratic, unorganized, frequent, often with a low or weak tone

Convincing, definitive, with sharp tone

Slow, avoidant, not much of a talker but a good listener, with a deep tone

My appetite is:

Inconsistent, changes based on the day

Strong, cannot tolerate skipping meals, get “hangry”

Weak, can easily skip meals

The activities that I like to engage in are:

Travel, dance, listening to music, running, socializing

Sports, discussing politics, competition, body building

Cooking, gardening, reading, spending time in nature, anything relaxing

My stamina is best described as:

Low, get tired easily, up and down

Steady and consistent from day to day

Strong and can keep going for many hours

The weather I prefer is:

Warm and humid

Cool and moderate

Dry and Warm

My immune system is:

Weak, fall sick with cold or flu multiple times per year

Moderate, prone to various infections in general

Strong, barely ever sick

Please answer the following questions based on your current habits over the last month.

Time I wake up:

Time I fall asleep:

Quality of sleep: (Select all that apply)

Consistent, restful sleep (7–9 hours most nights)

Usually adequate sleep with occasional disruptions

Difficulty falling asleep

Frequently wake during the night

Wake up feeling tired despite enough hours of sleep

Regularly get less than 6 hours of sleep

Irregular sleep schedule (shift work, changing bedtime/wake time)

Daytime naps:

Yes

No

What best describes your current level of movement/exercise?

How many hours per day do you watch tv, use the computer, look at your phone (any screen time):

What do you typically watch on TV?

What types of music do you listen to?

What are your social media habits?

I never go on social media

I briefly scroll, check messages, or post a status

I scroll or watch videos for 1 to 2 hours or more per day

Do you like to read?

What does your social life look like?

What are your hobbies or how do you like to spend your down time? How often do you get to indulge in these activities?

Rate the following 5 questions on a scale of 0-10, with 0 being none and 10 being the most.

How stressed are you?

How are your energy levels?

How happy are you?

How hungry are you at mealtimes?

Do you sweat easily?

Where were you primarily raised before age 18 (town, city, region, or general area)?

Were you or your recent ancestors born outside the US?

If you are 3rd generation American or less, where did your ancestors grow up? (Reply NA if > 3 generations in US)

Your Relationship With Food

What are your favorite foods?

What are your least favorite or least tolerable foods?

What do you typically eat for breakfast, including toppings, condiments, and drinks? (Reply NA if you skip this meal)

What do you typically eat for lunch, including toppings, condiments, and drinks? (Reply NA if you skip this meal)

What do you typically eat for dinner, including toppings, condiments, and drinks? (Reply NA if you skip this meal)

What snacks do you typically eat throughout the day?

What is your current ability and/or time to cook?

None

Once or twice per day

All meals

How many glasses of water do you drink per day?

Can you skip meals easily?

Yes

No

Do you feel irritable if you skip a meal?

Yes

No

Are you full at the end of your meals?

Yes

Yes, usually overfilled

No

Are you hungry before each meal?

Yes

No

How soon after a meal are you in the bathroom with a bowel movement?

How often do you consume the following?

Alcohol

Coffee

Tea

Energy Drinks

Tobacco

Marijuana

Fast Food

Please list any diagnosed medical conditions: (Reply NA if none)

Please list any surgeries or procedures involved in partial or full removal of any organs or major tissue. Also list all reproductive, pelvic, or abdominal surgeries/procedures performed: (Reply NA in none)

Please list all current prescription medications:

Please list all current vitamins, herbals, and supplements: