Intake Form What is your main health concern for you and your family? As a parent, what would you like to learn as a family with nutrition and lifestyle? What has proven effective in the past? What are your meals currently like and how many times a week do you cook? What is your family’s current diet like? Please be specific: list breakfast, lunch, dinner, and snacks, as well as the times you all eat. Do you and your family take any supplements? Please list what you take and what it’s for. What would you like to be doing as a family that you don’t do in 30 days from now? How about 90 days from now? What obstacles, challenges, and struggles do you have with regarding their diet/lifestyle? What do you hope to get out of our time together? What are 5 things your family does for fun or to be active? Send First Name* Last Name* Email* Preferred Phone * What is your main health complaint? * What is your Date of Birth * How often does it bother you? Everyday Once per week 2 to 3 times per week Once per month How long has it been going on? * 1-6 months 1-3 years Over 3 years What (or who) would prevent you from completing a health-rebuilding or weight loss program? Children Partner Time Self Money Fear Job Resources What have you tried so far that has or has not worked? * What is your current diet like? Please be specific: list breakfast, lunch, dinner and snacks, as well as the times you eat. * Are you taking any supplements or medications? Please list what you take and what it’s for. What would you like your health to be in 3 months from now? How about 6 months from now? * What obstacles, challenges, and struggles do you face regarding diet/lifestyle? * If we were to work together what would you expect to achieve from working with me? * What are 5 things you LOVE about your life? * How did you hear about or find (W)holistic Health Boss (me)?* Instagram Facebook Podcast Web Search Friend/Family If you selected Podcast or Family/Friend Referral, let me know who specifically in the box below so I can thank them? Yes! I want to get awesome health tips, tools and resources Submit Now
