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Client Intake Form
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2025-02-14T13:13:54+00:00
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Exercise: ? Communication
Services
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Nourish & Thrive
Renew & Reset
Rest & Restore
Glow Naturally
Personal Information
Name
*
Phone
*
Age
*
Preferred Communication Method
*
Email
Phone
Text
Email
*
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Occupation
On average, how many hours do you work per week ?
What are your personal health goals ?
Hobbies / Activities
What would you like to gain from working together ?
Lifestyle and Wellness
Current Diet:
Exercise Routine:
Stress Management:
Dietary Restrictions:
Current Activity Level:
Current Stress Level (1 is low – 10 is highest)
Selected Value:
0
Typical Daily Nutrition:
Types of Exercise:
Stress Coping Mechanisms:
Mineral Testing Consent
Are you interested in comprehensive mineral analysis?
Yes
No
Previous mineral or hormone tests:
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PCOS and Health Background
PCOS Diagnosis Date
*
Current Health Provider
Gynecologist
Endocrinologist
Primary Care Physician
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Nutritional Assessment Questionnaire
Check all that apply
Drink Alcohol ( Never / Monthly)
Artificial Sweeteners
Candy, Desserts, Refined Sugar
Carbonated beverage, include sparkling water
Chewing Tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Food
Luncheon Meats
Margarine
Radiation Exposure
Refined Flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweat
Restless leg syndrome
Crack on corner of mouth
Check all that apply
Experience pain relief with aspi
Crave fatty or greasy foods
Low or reduced fat diet
Tension headache at base of skull
Headache when out in the sun
Sunburn easily or suffer sun poisoning
Muscle easily fatigued
Dry flake skin or dandruff
Awake a few hour after falling asleep, hard to get back to sleep
Crave sweets
Bings or unconditionally eating
Excessive appetite
Crave coffee and sugar in the afternoon
Vitamins and Mineral Supplements
Sleep in the afternoon
Fatigue that is relieved by eating
Headache if meals are shipped or delayed
Irritable before meals
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Check all that apply
Shaky if meal delayed
Family members with diabetes
Frequent thirst
Frequent urination
Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in alms and legs
Enlarge heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart racing
Small bumps on back of arms
Strong light Ata night irritates eyes
Nose bleeds and /or twnd to bruise easily
Bleeding gums especially when brushing teeth
Other Concerns:
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Goals and Expectations
Primary Health Goals:
Specific Hair Health Objectives:
Expectations from the Coaching Program:
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