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Health Intake Form
leanneharris.com
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* Indicates required question
Name (first and last)
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Your answer
Email
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Your answer
Phone Number
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Your answer
Please tell me who referred you to me:
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Your answer
Do you take vitamins or other supplements?
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Choose
Yes
No
List all current prescription medications and any underlying medical conditions you've been diagnosed with.
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Your answer
In the last five years, have you taken any antibiotics? (If yes, please list them below.)
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Your answer
In the last five years, have you taken any vaccines? (If yes, please list them below.)
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Your answer
Why are you seeking help now?
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Your answer
What goals would you like to set for your health?
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Your answer
What all have you tried that has NOT worked for you?
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Your answer
Please list any unusual stress factors you’re facing
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Your answer
List any known allergies to food or medicine
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Your answer
Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent...
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Water intake (Ideal: body weight / 2 = total "ounces" daily)
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Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent...
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Sleep quality and time (Ideal: 8 hrs, uninterrupted, nightly)
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Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent...
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Exercise and movement (minimum = 30 minutes daily)
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Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent...
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Personal gratitude practice (reading, using affirmations, meditation and prayer, positive community)
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Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent...
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Fruits & Vegetables intake (minimum = a variety of at least 7 servings the size of your fist a day)
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Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent...
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Food quality (Ideal: Mostly organic, mostly raw)
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What times of day to you typically eat meals?
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Your answer
Do you frequently snack in between meals?
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Choose
Yes
No
Do you eat food products with dairy?
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Choose
Yes
No
If yes, please list
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Your answer
Do you eat food products with wheat / gluten?
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Choose
Yes
No
If yes, please list
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Your answer
Do you experience sugar cravings?
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Choose
Yes
No
If yes, please list
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Your answer
Do you eat food products with food dyes?
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Choose
Yes
No
If yes, please list
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Your answer
If yes, please list
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Your answer
Do you like to shop for food?
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Choose
Yes
No
Do you like to prepare meals?
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Choose
Yes
No
Are you interested in learning to shop differently and prepare meals that will support your health goals?
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Choose
Yes
No
Where are you on the motivation scale below?
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I NEED ACCOUNTABILITY
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I'M SELF-MOTIVATED
To be successful, who do you need support from?
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Your answer
Final Thoughts
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Please share any other information you feel is relevant to your health and health goals
Your answer
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