Intake Form.

Full Name

Date of Birth (dd/mm/yy)

Gender

Age

Email Address

Health and Medical History

Please list any current medical conditions or diagnoses (if applicable).

Please list any past medical conditions or diagnoses (if applicable).

Have you had any lab tests done within the last 6 months? (If yes, please email me a copy of the results)

YesNo

What treatment(s) (if any) have you tried for your medical conditions?

Are you currently taking any medications, pharmaceuticals, or supplements? If so, please provide names and dosages.

Have you ever had surgery? If so, please list the surgeries and approximate dates.

Do you have any known allergies or sensitivities (food, medication, environmental)? If so, please list them.

Lifestyle and Habits

What is your job?

Please describe your exercise or recreation routine:

On a scale of 1-10 (1 being the least and 10 being the most), how would you rate your overall stress levels?

What are your main sources of stress?

How many hours of sleep do you typically get per night? How do you feel when you wake up in the morning?

Do you currently or have you previously smoked?

YesNo

Body Measurements

Height (cm)

Current Weight (kg) - optional

Eating Habits

Please describe your typical daily diet (breakfast, lunch, dinner, and snacks).

How many times do you eat out per week? When you don't cook, where do you like to eat out?

What percentage of your meals are home-cooked?

Do you like to cook?

YesNo

What are your favorite foods, and are there any foods you avoid purely out of preference?

Nutrition Goals

What are your primary health and nutrition goals? What do you want to achieve from your nutrition consultation?

Social Support

Do you have any friends, family members, or colleagues who can support you in achieving your nutrition goals? If so, please describe.

Expectations

Do you have any other specific concerns, symptoms, or questions you would like to address during our session(s)?

Do you want me to add you to my email list to receive educational and inspirational content, news, and updates?

YesNo

Where did you hear about me? (Google, YouTube, Instagram, Vegan Magazine etc). Thanks!

Consent and Signature

By signing below I confirm that I have read and understand the information provided in this intake form. I acknowledge that the information provided is accurate and complete to the best of my knowledge. I agree to the Planted Nutrition Terms and Conditions (opens in new tab)

Signature

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