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Movement is Medicine

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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

Finish this sentence... "I

After I receive directions, I tend to...

Add answer here

Get in Touch

Let's build a daily routine you cannot wait to rise and run to everyday!

Same incredible YOU...We are just adding some new habits and lots more love!

Email: Danielle@DanielleBrodyWellness.com

Phone: (215) 694-1191

Based in Yardley, PA + Virtual Services

© 2021 Danielle Brody Wellness

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