Athlete Client Intake Form

Lifestyle
Do you feel tense?*
Do you feel a cold sensation in your hands or feet?*
Do you notice yourself yawning?*
Do you notice yourself breathing through your mouth at night?*
Do you snore?*
Do you experience fatigue and/or drowsiness during the day?*
Do you smoke?*
- Yes
- No
How many?*
Do you drink alcohol?*
- Yes
- No
How many glasses per week?*
How many hours do you regularly sleep at night?*
Describe your job:*
- Sedentary
- Active
- Physically demanding
Does your job require travel?*
- Yes
- No
On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?*
List your 3 biggest areas of stress:
1.)*
2.)*
3.)*

Nutrition
On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?*
What activities do you engage in while eating? (TV, reading, etc.)*
How many glasses of water do you consume daily?*
How many diuretics (caffeine [coffee, tea, etc.], alcohol, etc.) do you consume daily?*
Do you feel drops in your energy levels throughout the day?*
- Yes
- No
- Sometimes
When?*
How many times per week do you eat out?*
Do you do your own grocery shopping?*
- Yes
- No
Do you do your own cooking?*
- Yes
- No
List 3 areas of your Nutrition you would like to improve:
1.)*
2.)*
3.)*

Miscellaneous
How did you hear about us? Please check that which applies.*
- Brochure
- Word of mouth
- Yelp
- Website
- Other
If "Other" above, please tell us how you heard about us?
If you were referred to us, who told you about our services?
You will be contacted within 24 hours. Assuming it makes sense to move forward, what days and times are you availble for your 75-minute, initial appointment/assessment?
Verification
Comments
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Personal Information