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Client Intake Form
Please complete the following form to help me understand your body, lifestyle, and goals.
Full Name *
Email *
Phone Number
Address *
Address *
Address line 2
City *
State / Region
Postal / Zip Code *
Country *
Ireland
Age *
Height *
Weight *
Goal weight *
Gender *
Have you seen a Dietitian/Nutritionist in the past?
Yes
No
If yes, When?
Reason?
Diet & Lifestyle
How would you describe your current diet?
Choose the one that fits you best.
Vegan
Vegetarian
Mediterranean
Standard diet
I eat everything
Other
What does a normal day of eating look like for you? *
Wright from morning until the evening; be as detailed as you can
How active are you?
Think about your average week.
Sedentary (little or no exercise)
Light (1-2 days per week)
Moderate (3-4 days per week)
Very active ( 5+ days per week)
Types of physical activity? *
How many hours do you sleep per night (on average)? *
Any sleep interruptions? *
How is your stress level at the moment? *
Source of Stress? *
Health background
Do you have any of the following? *
Tick all that apply.
High cholesterol
High blood pressure
Diabetes
Gut issues ( bloatting, constipation, IBS)
PCOS
Thyroid problems
Fatty Liver
Other
None
Blood Tests *
Do you take any medication or supplements? *
Family Health History *
Please identify any significant health problems amongst your father, mother, siblings, grandparents (maternal and paternal), and/or children.
Describe any symptoms you experience regularly. *
Do you have any food allergies or intolerances? *
Is there any food you absolutely dislike or prefer to avoid?
Occupation *
I Live
Alone
With a partner
With children
With parents
Other
Who does the grocery shopping? *
Who cooks? *
How hoften do you eat out *
Are you dieting?
Yes
No
If "Yes" are you on a prescribed medical diet?
Yes
No
Have you experienced any of the following?
Skip meals to reduce calories
Purging/making yourself sick after eating
Eat large quantities of food at one time
Over exercising
Use of laxatives for weight loss
Obsessive thoughts of food or weight
Feeling out of control when eating
None
Numbers of meals you eat in a day *
Numbers of snacks you eat in a day? *
How would you rate your salt intake?
Low
Moderate
High
How would you rate your fat intake?
Low
Moderate
High
Do you drink Caffeine?
Coffee
Tea
Cola
Other
None
Number of cups/cans per day.
Are you a smoker?
Yes
No
Do you drink alcohol?
Yes
No
If "Yes" how often?
SELF-ASSESSMENT
What is your health goal? *
What is your biggest obstacle to reaching your goal? *
On a scale of 1to 10, how would you rate the importance of making changes to benefit your health? *
Not important =1 and Very important= 10
On a scale of 1 to 10, how would you rate your confidence that you will be successful in making changes to benefit your health? *
Not important =1 and Very important= 10
Consent *
Please read and tick the box to continue.
I understand this is nutrition and lifestyle guidance only and does not replace medical advice. I consent to sharing this information to receive a personalised plan from Healthify by Nina.
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