Keto 101 Intake
Please fill out this form the best you are able before we have our pre-program call.
Email *
Name *
Phone Number *
Date of Birth *
Gender *
Height & Weight *
Current Weight/ Goal Weight/ Weight 1yr ago *
How many hours of sleep do you get per night? *
Do you exercise? How often? What do you do? *
Do you drink alcohol? How often? *
Do you smoke? How often? *
Recreational dug use? How often? *
Children? Ages? *
What is your family living situation? *
What do you do for work? *
What do you do for fun? *
On a scale of 1-10, What is your stress level? *
What is the cause of your stress? *
Have you had any recent life changes or big events? *
Current medications? *
Do you have a bowel movement at least once per day? *
Have you ever been diagnosed with IBS or GERD? *
Are you diabetic? *
Do you have hormonal issues? *
Is your period regular *
Do you have any thyroid issues or concerns? *
Have you ever or do you currently suffer from depressions or anxiety? *
Any injuries? *
Please list all surgeries *
Do any chronic diseases run in your family? *
Any other health concerns or conditions? *
Any food allergies? *
Favorite Food? *
Food you do not like? *
Do you emotionally eat? *
Do you eat out of boredom? *
What does your typical day of eating look like for you? *
What do you like to order when dining out at a restaurant? *
How many glasses of water do you drink per day? *
What are your health goals and aspirations? *
Why are these important to you? *
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