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Danielle Brody Wellness
Your Modern Health Partner
Let's Get to Know YOU!!
New Client Intake Form
Welcome!
First Name
Last Name
Email
How did you hear about us?
Friends
Social Media
Other
Phone
What are you interested in?
Nutrition
Personal Training
Life Coaching
3 Month All-Inclusive Package
Tell me what you are most excited to learn more about and to gain support in?
What is your current occupation and/or daily responsibilities? Would you consider your daily responsibilities stressful? What does a "normal" day look like?
What is your current activity level? Are you interested in incorporating activity into our program? If so, what activities interest you? Name 3
What is your #1 goal with our time together? What is your #1 reason WHY?
Please list any relevant medical conditions, medications or anything you are under a physician's care for.
If you have sought nutritional guidance before, what approaches did you enjoy best? Not which you had the "best" results from...which did you find enjoyable and easy to incorporate into your daily life?
Are you taking any non-prescription supplements? Nutritional supplements? Vitamins? Minerals? Herbs? CBD?
Hydration: How much water do you currently drink a day? (approximately) Is your urine typically clear, light yellow or dark yellow?
Digestion: How frequently do you move your bowels? It is usually in the AM or PM?
Add answer here
Do you get outside every single day?
Every single day!
Most days
Not as much as I would like to
Do you enjoy outdoor time or activities?
Very much!
Not really
Energy: How would you describe your energy level? (1 being low, 10 being high) Also, when do you have the MOST energy each day? DO you notice a pattern?
Sleep: How many restful, uninterupted hours of sleep/night are you currently getting? What does your sleep routine look like? (ie TV on? Sound Machine? Frequent Waking?)
Stress: On a scale from 1-10, how would you describe your current stress level on a daily basis? (1 being unmanageable, 10 being well managed) What are some tools you currently utilize or enjoy for stress relief?
Is your period regular?
Yes
No
Are you currently on birth control?
Yes
No
Do you have any food allergies, intolerances or aversions?
Are there foods you like to enjoy every day?
What percentage of your meals are home cooked?
100%
75%
50%
0-25%
What percentage of your meals would you prefer, ideally, to cook yourself?
100%
75%
50%
0-25%
How proficient are you in home cooking?
I am a newbie, but am eager to learn!
I know a little, but am ready to learn more!
I really do not like to cook at all, but know it is important so I am willing to learn!
Which restaurants do you order, pick up or visit in person from your area?
Is there anything you want me to know about your current or past relationship with food?
When given directions, I tend to
Choose an option
Finish this sentence... "I
Choose an option
After I receive directions, I tend to...
Choose an option
Add answer here
Terms & Conditions
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