CLIENT ONBOARDING
Personal Information
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Middle Name
Last Name
Prefferred Name
Referred By
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
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26
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29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Primary Phone
*
E-mail
*
example@example.com
Best way to contact?
*
Primary Physician
*
Name and contact information
Age
*
Height
*
Please specify if Feet or Centimiters
Place of Birth
City and Country
Genetic Background
*
African American
Native American
Mediterranean
Hispanic
Caucasian
Northern European
Asian
Other
Relationship Status
*
Single
In a relationship
Married
Divorced
Widowed
Job Title and Company
*
How many hours of work per week?
*
I work Part Time (up to 30 hours a week)
I work Full Time (35 - 45 hours a week)
I work overtime (48 - 72 hours a week)
I never stop working
HEALTH INFORMATION
What blood Type are you?
*
0 positive
0 negative
A +
A -
B +
B -
AB +
AB - (negative)
Not sure
Please describe which one
*
Current Weight
*
In LBS or KG please
Your weight 6 months ago
*
In LBS or KG please
Your weight a year ago
*
In LBS or KG please
What's your daily energy level like on a scale 1 - 10?
1
2
3
4
5
6
7
8
9
10
When do you feel the most tired?
Mornings
Evenings
The whole day
How often do you feel sad, depressed or unhappy?
Never
Rarely
Once in a while
Always
How is your elimination?
1 Time a day
1 - 3 Times a day
Every other day
Few times a week
Please select if you suffer with any of these symptoms
*
Slow awakening
Gastritis
Headache
Poor blood circulation
Low energy
Swelling (legs, feet, hands etc)
Pimples
Fragile nails and hair
Dandruff
Constipation
Diarrhea
Irregular Periods
Hemorrhoids
Psoriasis
Liver Problems
Blood Pressure Issues
Thyroid Problems
Allergies
Asthma
Cholesterol
Intolerances
Other
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Food Information
Please select what is your current diet
*
Omnivore (No food restrictions, eat everything)
Vegetarian (Plant based + eggs + diary)
Pescatarian (Plant based + fish + possibly eggs and diary)
Vegan (100% only plant based)
Raw Food
Paleo Diet
Ketogenic Diet
FODMAP's Diet
Other
When do you feel the most hungry?
Mornings
Evenings
The whole day
In the middle of the night
What do you snack on?
Fruit / Veggies / Hummus / Guac
Chips and crackers
Bars
Sweets / Chocolate / Cookies
Vending machine food
Other
Do you have a sweet tooth (crave sweets)?
NOPE
Occasionally
I can't go a day without something sweet
Other
How much water do you drink a day?
1 - 3 glasses a day
7 - 10 glasses a day
4 - 6 glasses a day
2 Liters (1 gallon)
How many times a week do you eat out?
0
Type option 1-3
4 +
What's the average cost per meal out?
How many times a week do you eat bread, bagels, cereal, pasta or baked goods?
Rarely
2 - 3 times a week
Almost every day
Every day
With every meal
How many times a week do you eat vegetables?
Rarely
2 - 3 times a week
Almost every day
Every day
With every meal
How many times a week do you eat fruits?
Rarely
2 - 3 times a week
Almost every day
Every day
With every meal
Do you drink Soda / Energy Drinks or any other fizzy drinks?
Never
Once a week
Once a month
Once a day
Multiple times a day
How often do you eat fast food?
Never
Rarely (a few times a year)
Once a month
Once a week
Once a day
Multiple times a day
Do you drink Coffee?
Never
Once a week
Once a month
Once a day
Multiple times a day
Please select what of the following Lifestyle habits may apply to you
*
Eat out often
Often eat home
Can't cook
Can cook
Love to cook
Travel frequently
Often eat alone
Often eat socially
Live alone
Live with other people
Confused about food/nutrition
Time constraints
Family members have different tastes
Rely on convenience items (boxed goods, frozen meals, ready-to-eat meals)
Poor snack choices
Do not plan meals
Often tired after work
Please select what of the following eating habits may apply to you
*
Fast eater
Slow eater
Struggle with eating (Under eat)
Eat with moderation
Over Eat
Don't enjoy eating / I eat because I have to
Love to eat
Negative relationship with food (afraid to eat, feel guilty when eating etc)
Irregular eating patterns (sometime skip meals)
Emotional eater (depending on mood you eat more or less)
Dislike "healthy food"
Late night eating
Salt tooth (prefer salty items)
Sweet tooth (prefer sweet items)
I love cheese
Other
Is there anything else about your nutrition/eating habits that you would like to share?
*
Women's Health
How long is your flow?
3 days
5 days
7 days
Other
Do you experience any specific symptoms?
Are you currently on any birth control?
NONE
Pill
Vaginal Ring
IUD
Patch
Shot
Diaphragm
Implant
Other
Reflection
What other wellness programs / products have you tried in the past to achieve your nutrition goals?
What results have you experienced with these programs / products?
What do you think did not work?
What do you hope to achieve with the program?
*
What is your main health concern
*
Can you recall when was the last time you felt well?
*
Did something trigger your change in health?
*
When do you feel your best?
When do you feel your worst?
What would you like to achieve in one month?
What would you like to achieve in Three months?
Additional Comments:
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PHYSICAL ACTIVITY
Please indicate the type of exercise you are currently engaging in.
*
Type/Intensity (low/mod/high)
# Day Per Week
Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other
Please list what:
*
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WHEEL OF LIFE
Rate on a scale of 1 (not) to 10 (highly) how satisfied are you with the following:
Health
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Work
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Family
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Relationships
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Love
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Finances
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Education
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Physical Activity
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Career Choice
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Recreation / Fun
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Other
LIFESTYLE
Please explain:
*
How do you handle stress? Please explain:
*
What makes you happy / When do you feel relaxed and balanced?
*
If yes, how many times? Why?
Please rate the overall quality of your sleep
1
2
3
4
5
6
7
8
9
10
How many hours of sleep do you get a night?
0 - 3
4 -5
6 - 7
8 -9
In order to improve your health, how willing are you to:(Rate on scale of 5-very willing to 1-not willing)
5
4
3
2
1
Significantly modify your diet
1
2
3
4
5
Take nutritional supplements each day
6
7
8
9
10
Modify your lifestyle (work demands, sleep habits, exercise)
11
12
13
14
15
Practice a relaxation technique
16
17
18
19
20
Engage in regular exercise/physical activity
21
22
23
24
25
Take periodic pictures to track your progress
26
27
28
29
30
Any additional comment?
*
Submit
Should be Empty: