Intake Form

Client Intake Form

How did you hear about us?

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Personal Information:

Client Name:

Date of intake:

Phone Number:

Age:

Gender:

Height:

Weight:

Goal weight:

Neck Measurement

Hip Measurement

Waist Measurement

What have you heard about a ketogenic lifestyle?

What is your reason for wanting to learn more about ketogenic lifestyle?

What are your goals?

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Health History:

Medical History? (Please include all health conditions for which you have been treated and/or suffer from including hormonal issues)

Do you suffer from anxiety or depression?

Do you experience dry skin or eyes?

Do you take ANY Medications/Multi-vitamins/other supplements? PLEASE LIST ALL

Have you been yo-yoing with weight and/or diets?

Do you bruise easily?

Any issues with sleep patterns?

Any Issues with bloating?

Do you have any recent lab values available for but not limited to: (Please list any additional)

Thyroid?

Vitamin D?

Iron levels?

FASTING blood glucose levels?

Triglycerides?

Additional Labs:

FINGERNAIL HEALTH

FINGERNAIL HEALTH:

Thin/Flat nails?

White spots on nails?

Ridges on nails?

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OTHER:

Do you experience PMS?

Menstrual Cycle (How Many days is your Cycle):

Cuts heal slowly and/or scar easily?

Calf, foot or toe cramps at rest?

Do you feel you have lost vitality and sense of awareness or someone who ‘fakes’ their energy level?

Do your feet have a strong odor?

Abnormal cravings for substances other than food, such as paper, dirt, clay, rubber or ice?

Yeast & Fungal Infections?

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LIFESTYLE:

Alcohol: How many drinks per day/week?

Coffee: Drinks per day/week?

Drugs or other Chemical Dependencies?

Smoking: Packs per day/week?

Water: approx. how may cups per day?

Hobbies?

What is your typical Breakfast like?

Lunch?

Dinner?

Snacks?

What is your current exercise level/schedule?

Do you have a bowel movement every day? Any Indigestion/Acid Reflux?

Cravings?

Are you tired or energetic after you eat?

2976 E State St Suite 110

Eagle, ID 83616

208-506-0099

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