CLIENT INTAKE FORM If you are a human and are seeing this field, please leave it blank. First Name Last Name Email Contact Phone Number Date of Birth Height Weight Are You Happy With Your Weight? YesNo Would you like to change your weight, and if so - how? Relationship Status Pets Occupation Hours Worked Per Week Main Health Concerns Current Struggles Current Goals Time frame you would like to achieve goals Describe your daily routine Describe what you normally eat throughout the day Do you take any supplements or medications? Please list. Are you currently seeing any health professionals? Do you have a support system? Do you have anything you would like to share, or that you feel I need to know?