Client Intake Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

In order for me to provide you optimal service as a food health coach, please complete this form to the best of your ability.

How did you hear about Food Brilliance? *

Your current situation

1. What is the main reason you are seeking a food health coach? *

(e.g. – a current health concern, the desire to learn more about maintaining a healthy lifestyle, or even the desire to learn more about cooking healthy food)

2. What are your health concerns? *

3. Do you have a health goal? If so, what is it? If not, would you be willing to create one? *

4. Do you have any dietary restrictions? List and explain. *

5. WHAT FOODS DO YOU EAT NOW? PLEASE PROVIDE A SAMPLE OF FOODS YOU EAT DURING A 3-DAY PERIOD.

Breakfast *

Lunch *

Dinner *

6. What foods work well for you? What foods do you have a hard time digesting? *

Getting to know you more

1. What foods did you grow up eating? *

2. How is your appetite? In the morning? After lunch? In general? *

3. Do you get food cravings? If so, what are your cravings? When do you usually have food cravings? *

4. What foods do you like? What foods don’t you like? *

5. Do any members of your family have food allergies or dietary restrictions? *

Bonus Questions. These questions will allow me to achieve a more holistic understanding about you and your life.

1. Are you willing to try new foods? *

2. Would you consider yourself an adventurous eater? *

4. How much water do you drink a day? *

5. Do you often feel fatigue? If so, what time of the day does this feeling occur? *

6. Do you feel satisfied after you’ve eaten? *

7. Do you snack between meals? If so, what do you snack on? *

8. Are you interested in learning about healing teas? *

9. Is there anything else you would like me to know about you? *

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