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Health Client Information Form

Gather the three concerns a client most wants to work on, plus medication, supplements, meals, sleep and exercise habits. A willingness scale shows how ready they are to change what they eat. Nutritionists and functional health practitioners can prepare before the first consultation.

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Full name*

First Name

Last Name

Email*

Phone number

How old are you?*

What is your top health concern?*

Tell me more: when was it diagnosed, are you on medication, is it controlled, and what do you hope to achieve?*

What is your second health concern? Type NONE if there is none.

Tell me more: when was it diagnosed, are you on medication, is it controlled, and what do you hope to achieve?

What is your third health concern? Type NONE if there is none.

Tell me more: when was it diagnosed, are you on medication, is it controlled, and what do you hope to achieve?

Tick anything you have experienced in the past 12 months:*

Unexplained weight change Digestive discomfort Persistent fatigue Frequent headaches Skin problems Mood changes Sleep problems None of these

List the medication you have been prescribed and say whether you still take it. If none, type NONE.*

List the supplements, herbs and vitamins you take and why. If none, type NONE.*

How often do you exercise and how long have you kept it up?*

What kind of exercise do you do?*

What does a typical breakfast look like?*

What does a typical lunch look like?*

What does a typical dinner look like?*

Which foods do you crave most?

How many hours do you sleep a night and do you wake up rested?*

How many cigarettes or cigars do you smoke a day or a week?*

Is there anything else I should know before your appointment?*

How willing are you to change what you eat?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Will the people you live with make these changes with you?*

Would you like to receive our newsletter?*

Yes No

How did you hear about us?*

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