LIFESTYLE INTAKE FORM & HEALTHY LIVING ANALYSIS

Full Name

First NameLast Name

What is your gender?

Contact Phone Number

Birthdate

Date

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Height

Weight

Ideal Target Weight

Approximate Body %

Are you happy with your energy levels and how you feel day to day?

Please elaborate further if you would like to

Are you happy with how your body looks?

Please elaborate further if you would like to

Race / Nationality

Are you married or do you have a significant other?

YESNO

If, Yes. Spouse or partner's name

Spouse or Partner Date of Birth

Date

Do you own your own business or are you self employed?

Please list current and or past occupations / jobs?

What is your DREAM occupation, career or job?

Education Level

Do you have any children? (child age or adult aged)

Please list the gender and ages of each of your children

Does your spouse or any of your children suffer from any chronic ailments or diseases that we should be aware of?

Check the conditions that apply to you or any member of your immediate family:

Check the symptoms that you' re currently experiencing:

Check the following physical activities that you have engaged in at least once in the last seven day:

Check the following mental activities that you engage in at least once per week:

Are you currently taking any pharmaceutical prescription medication(s)?

YesNo

If Yes, please list them.

Have you taken an ALCAT or food allergy / food sensitivity test?

YesNoNot Sure

Do you consume junk food? (candy, chocolate, sugars, potato chips)

How much sleep do you average per night?

How many times per week do you go to the bathroom, bowel movements (elimination)?

Have you noticed any changes in your bowel habits or any rectal bleeding?

Have you had a physical in the last 12 months?

Have you had a colonoscopy in the last 2 years?

Have you had a mammogram screening in the last 2 years?

Do you currently have health insurance?

Yes, Excellent coverageYes, medicare / medicaid or limited coverageNo, I do not have coverageIt's complicated

Do you have life insurance?

Are you color blind?

Do you consume milk and dairy products (cheese, butter, yogurt, mayo, creamers )

Do you consume animal red meat? (beef, pork, bison, bacon, ham, sausage)

Do you consume turkey, chicken, hen, duck or eggs?

Do you drink coffee?

Do you drink soda or energy drinks?

Have you used CBD in any form in the last 15 years?

How many ounces of water do you drink per day?

Do you currently use or have you used any kind of tobacco products in the past 15 years? (cigarettes, chew or dip, vape pens)

Do any of your current or immediate family members smoke cigarettes?

Do you use any kind of illegal drugs or have you ever used them in the last 5 years? (confidential information is not to shared by our staff)

How often do you consume alcohol?

P.P.A. HEALTH & WELLNESS LIFESTYLE INTAKE EVALUATION & HEALTHY LIVING ANALYSIS