New Client Intake Form Name First Name Last Name Email * Phone (###) ### #### What program are you interested in? * If you're unsure, you can select more than one. Introductory Coaching Monthly Coaching Multi-Month Coaching FASTer Way 6 Week Challenge Do you drink alcohol? If yes, how many drinks a week? * Have you had any surgeries in the past year? If yes, please describe. * Do you have any digestion issues? * Do you currently experience any chronic disease? Please describe. * Diabetes, high cholesterol, chronic inflammation or any type of hormonal imbalance How well do you describe your sleep? Not great, only 3-4 hours per night Moderate, between 4-6 hours per night Good, +7 hours per night Please list the medications and/or supplements you're currently taking * Are you familiar with tracking your daily food intake? If yes, what do you normally use? * How would you describe your meal sources? * Mostly homemade 50/50 homemade and eat out Mostly eat out Do you have any food allergies or sensitivities? Please describe. * How many meals do you normally have on a given day? * Can you explain on average at what time is your first and last meal in a given day? * Do you participate in any type of exercise? Can you please share how frequent and how long? * Please select the reasons you eat (besides hunger). * You can select more than one. stress happiness depression boredom anxiety What are your goals from a nutrition perspective? * Thank you! I’ll get back to you shortly.