Initial Intake Questionnaire

1. ➜

First Name

2. ➜

Last Name

3. ➜

E-mail Address

4. ➜

Phone Number

5. ➜

What is your occupation?

6. ➜

What is are your key health challenges and main concern right now?

7. ➜

What are you trying to do right now to change this (diet, lifestyle and supplement wise)?

8. ➜

What have you tried to do to solve your health challenge in the past that didn't work?

9. ➜

Is there anything that you've done in the past that helped, but you aren't doing anymore? Why?

10. ➜

Is there something that worked in the past, but doesn't seem to be working anymore?

11. ➜

What from your perspective do you think is at the root cause(s) of your issue?

12. ➜

What in particular is motivating you to do what it takes to reach out to get support now?

13. ➜

Why is overcoming your issue a priority now?

14. ➜

Which of the following apply:

I have a health issue that I want to resolve

I want to achieve my ideal body weight and shape

I want to attain a higher level of health than I have ever experienced before

15. ➜

Please list all diagnoses (past and present), plus any surgeries you've had:

16. ➜

Please list all medications and supplements that you take:

17. ➜

Anything else you would like me to know?

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Sherry Rothwell