IAWP Students Wellness Intake Form

Coach Neshama

step into your body...step into your life
Short Wellness Intake Form
Today's Date:

MonthDayYear
Date
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Cell phone:

Area CodePhone Number
OK to text?

YesNo
Age:
Date of Birth

MonthDayYear
Pronouns
Current Weight:
Weight One Year Ago:
Ideal Weight:
Occupation:
Please rate your stress levels on a scale of 1-10 (10 being high):

1=very low stress; 10=very high stress
How would you rate the pace of your life?
Do you experience any troubles with digestion? (constipation, diarrhea, IBS, colitis, acid reflux, etc.)
How do you sleep at night?
How much water do you drink per day?
Do you eat when you are bored?
Do you eat when you are stressed?
Would you describe yourself as:

A slow eaterA moderate eaterA fast eaterIt depends
Do you have challenges with portion control?
Are you addicted to any of the following

caffeinesugaralcoholcigarettesOther
How often do you exercise?
What type of exercise do you like best?
Have you tried health / weight loss / nutrition / wellness programs in the past?
If you have tried any programs, what were they, when did you do them and were they successful?
Have you ever received treatment for an eating disorder? Please answer yes/no and explain if yes.
Do you take any medications / supplements, if so please list:
Therapies you are currently doing (i.e. mental health, massage, or other):
Please detail the foods you typically eat for:
Breakfast:
Lunch:
Dinner:
Snacks:
Beverages:
What are your major health concerns?
What would you like to be different 6 months from now?
What is holding you back from being healthier?
Is there anything else that is important to know regarding your health that you have not mentioned?
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Coach Neshama

Short Wellness Intake Form