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Duration: 90 minutes
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Client Intake Form © 2020 Kymberley Pekrul | G-Free Deliciously®-Deliciously Well Health Coaching Services™

Congratulations on taking the very first step in your Amazing, Glorious Journey!

Thank you for taking the time to answer a few short questions that will help you get the most out of our time together. The questions below are essential in providing details of your health, goals, and medical history. Please submit the completed Intake Form at least 24 hours before your session.

See you soon!
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Health & Lifestyle Coach | Gluten-Free Nutrition Specialist
Awesomely trained in TCM at HCI


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Personal Information

 Client First Name Client Last Name
 [clientFirstName] [clientLastName]

Date of BirthRelationship status
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Please selectSinglePartnershipMarriedDivorcedPrefer not to say{"type":"select","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Please select\nSingle\nPartnership\nMarried\nDivorced\nPrefer not to say"}



Preferred method of contact for coaching:

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Health Concerns

What is your main health concern or the biggest challenge that you're facing right now (and how long has this been an issue)?
Describe in detail, including the severity of the symptoms.
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Treatment History 

What have you done in the past to work on this? Include both alternative and traditional modalities.
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What has proven effective for you in working on this problem or challenge?
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Any testing for celiac disease?
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If Yes, results?
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List all vitamins, minerals, herbs, and nutritional supplements you are now taking.

NameDosageFrequencyDurationComments
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Does anyone in your family, including you, have allergies of any kind?
In other words, cat, dust, pollen, food, medications, etc.
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If Yes, who? What kind?
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Are there any foods that "don't agree" with you?
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If Yes, what kind?
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Do you experience any of the following symptoms or conditions frequently?
Use the following remarks to indicate frequency and severity:

D=Daily

 W=Weekly

O=Occasionally

 S=Severe

 M=Mild/not severe

 Fatigued{"type":"text","name":"symptomCondition2","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



 Restless/Hyperactive{"type":"text","name":"symptomCondition13","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


General Malaise (feel lousy){"type":"text","name":"symptomCondition3","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Sleepy during the day - Insomnia at night{"type":"text","name":"symptomCondition14","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Depressed/Mood swings/Irritability{"type":"text","name":"symptomCondition4","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Migraine{"type":"text","name":"symptomCondition15","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Headaches other than Migraine{"type":"text","name":"symptomCondition5","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Stuffy or runny nose{"type":"text","name":"symptomCondition16","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Brain fog{"type":"text","name":"symptomCondition6","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Throat clearing{"type":"text","name":"symptomCondition17","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Sinus problems{"type":"text","name":"symptomCondition7","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Muscle or joint pain{"type":"text","name":"symptomCondition18","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Dark circles/puffy eyes{"type":"text","name":"symptomCondition8","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Water retention{"type":"text","name":"symptomCondition19","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Heartburn/Reflux{"type":"text","name":"symptomCondition9","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Canker sores/Mouth sores{"type":"text","name":"symptomCondition20","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Constipation{"type":"text","name":"symptomCondition10","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Dizziness{"type":"text","name":"symptomCondition21","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Abdominal pain{"type":"text","name":"symptomCondition11","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Rashes{"type":"text","name":"symptomCondition22","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Bloating, distension, gas{"type":"text","name":"symptomCondition12","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Body/Muscle aches{"type":"text","name":"symptomCondition23","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


 Diarrhea/Loose stools{"type":"text","name":"symptomCondition24","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


  Weight problems{"type":"text","name":"symptomCondition25","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



Have any other family members had similar problems (please describe)?
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Eating Habits/Lifestyle Considerations

 What is your occupation? Hours per week
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What is your current diet like?
Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.
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How often do you cook from scratch?
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How often do you eat out?
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Do you tend to skip meals?
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Do you ever eat for comfort?
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How do your health problems interfere with your life?
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What foods (if any) do you crave?
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Are there any foods you could not give up for two weeks?
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How badly are these problems affecting your life?
1=Does not affect my life, 10=Affects my life greatly

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{"type":"radio","name":"__generic92","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"9"}


{"type":"radio","name":"__generic93","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"10"}



How committed are you to getting better?
1=Not very committed, 10=Very committed

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{"type":"radio","name":"__generic99","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"6"}


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What would you like your health and life to be like 30 days from now? How about 90 days from now? How would you feel if you got this result?
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Are there any other challenges, obstacles, or struggles regarding your diet/health/lifestyle?
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What do you hope to get out of our time together?
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What are five things you LOVE most about your life?
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Is there anything else you'd like me to know?
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