FAB OVER 40
Health and Fitness
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Health Intake Form
Name
Date of Birth
Phone
Email
Medical History:
Current or chronic medical issues
Do you take any medications / supplements?
Exercise:
How many days per week do you exercise?
How long do you exercise for per day? (in minutes)
What type of activity / exercise do you participate in?
Have you tried health / weight loss / nutrition / wellness program in the past?
Choose an option
Yes
No
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If so please list the programs and if they were successful?
Nutrition:
What types of foods to you generally consume in a day? Do you snack?
Do you experience any problems with digestion? (constipation, diarrhea, IBS, acid reflux, etc)
Do you have any food allergies/sensitivities? If yes, please list:
Do you
Eat when you are bored?
Eat when you are stressed?
Have difficulty with portion control?
How many glasses of water do you drink a day?
Have you ever been told by a doctor to follow a specific nutrition plan( weight loss, diabetic, low cholesterol, cardiac, etc)?
Choose an option
Yes
No
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Are you currently following a nutrition plan (diabetic, gluten free, low lactose, low cholesterol, vegetarian, vegan, etc) If so, list below:
Sleep and Stress:
How many hours of sleep do you get on average?
Stress: Check any symptoms below that apply to you:
Minor problems throw me for a loop
I am unable to stop thinking about my problems
I feel frustrated, impatient and angry much of the time
I feel tense and anxious much of the time
I have difficulty managing my time, such as work, family, meals, etc
Have you suffered a personal loss or misfortune in the past year? (Ex, a job loss or change, divorce, separation, disability, or the death of someone close to you?)
What have been some of the health challenges/obstacles that you encountered in the past? Check all that apply to you:
Limiting sweets/desserts
Eating when not hungry
Eating too large of quantities
Food cravings
Lack of motivation
Lack of physical activity
Limiting high sugar beverages
Skipping meals
Emotional eating (stress, upset, happy, etc)
Unsure about what to eat
Problems with goal setting
Lack of appetite
Eating too fast
Difficulty with cooking
What are you major health/fitness/wellness concerns?
What changes are you ready to make within the next 60-90 days to improve your overall health?
Would support with your health and wellness goals be of interest to you?
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