CLIENT INTAKE FORM

NAME
PHONE
*Please answer the questions below.
How did you learn about us?
If referred, please state their name and mobile number.
Do you work?
If yes, is it a desk job? Or does it include any movement? Kindly share your working hours.
Are you pregnant?
If yes, how many weeks? Is this your first pregnancy? What is your pre pregnancy weight?
*Please answer the questions below.
Are you on any medication or supplements?
If yes, please share dosage and pictures.
Do you exercise?
If yes, how many times per week?
*Please mark any of the following conditions you may currently have.
Others, please specify:
*Please answer all the questions below.

Tell me more about your current lifestyle. Is it stressful and do you feel you are in control of your eating habits? Would you say you are motivated to change or need a push?
Q1. FOOD LOG - Can you give me an example of the meals you eat with the timing of each meal. Please include snacks, coffee/tea, and your water intake.
Q2. Are you breastfeeding? If yes, are you exclusively breastfeeding or mixing with formula? Do you breastfeed directly or pump? How long would you like to breastfeed ideally? (If no, kindly skip)
Q3. How many hours of sleep do you get on average? Please share your average bedtime and usual time you wake up in the morning.
Q4. Do you know of any food allergies? If yes, please list them for me.
Q5. Do you have any food dislikes that I should not include in your meal plans? If yes, please list them for me.
Q6. What is your highest and lowest weight reached in the past 5 years?
Q7. What is the weight you would feel happy and comfortable reaching?
You have successfully subscribed!
This email has been registered
Close