Hormone Consultation Intake Form

Please fill this out to the best of your ability.

Today's Date

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

DOB

Current Weight

Height

Tell Me About You:

What time do you go to bed?

What time do you wake up?

If you have any variances in your schedule, please describe below:

Briefly describe your short and long term goals:

What is your occupation? Please indicate what a day is like for you ex. on my feet all day, high stress work environment etc.

What are one or two things that me as a coach can help you be most successful in this process?

***STARTING PICTURES ARE A REQUIREMENT BEFORE BEING ABLE TO START *** Please take a front, side, and back picture in good lighting with no shadows. Ladies- a swimsuit, posing suit, sports bra/booty shorts are great Men-Compression shorts or briefs rolled up without a shirt.

Upload Front Image

Upload Side Image

Upload Back Image

Lifting & Cardio

What time of day do you typicall work out?

What gym do you workout at? What kind of a gym is this?

What are your current "splits"?

How many days have you lifted in the past month?

What is the duration of your workout?

What kind(s) of cardio have you done in the last month? ex. duration, tempo etc.

What cardio/workout/diet regimens have worked for you in the past?

Health History

List any pre-existing health conditions that you have been diagnosed with:

Please provide a detailed explanation, including date of diagnosis:

What issues do your pre-existing health conditions create for you?

Have you ever had organ(s) removed?

If you answered yes please provide date(s) and specify what organ(s)

What is your blood type?

Any current or past injuries/limitations? Please provide details:

Are you currently taking any medications, prescribed or over the counter? If so, please list each and provide dosage:

Please list all supplements you are taking and provide doses. This includes vitamins, protein powders, fiber etc.:

Females, please answer the following:

First day of last period:

How many days is a normal cycle for you (the day you get your period is day 1 of your cycle):

Is your cycle normal? If not please explain:

What type of birth control are you using?

Have you had children before? If so, how many, what are their ages, and did you breast feed? If you had a child within the last 2 years and breast fed, please explain how long you breast fed for. (Leave blank or type NA if it's NA)

Explain to me your main issues you are having in relation to your hormones and symptoms you are experiencing. (N/A if this doesn't apply to you)

If you have any issues listed above, please explain how long these symptoms have been going on and when they started.

Do you have any hair loss, hair breakage, thinning of hair, or brittle nails? If so, please explain:

Explain to me your main issues you are having in relation to your hormones and symptoms you are experiencing:

Do you have any recent lab work from the past 6 months? If so and you are willing to share, please attach below.

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Nutrition

Does your schedule allow you to consume meals when needed throughout the day? If you have time restrictions what are they?

What supplements are you taking? Please list ALL, specific brands, AND doses.

Do you have a DIGITAL food scale that you can measure both ounces and grams? (If not, you will need one)

Do you have any food allergies or restrictions? If so, what are they?

How much water do you consume on average each day?

What kind of caffeine do you consume? How much do you do each day?

What are your favorite healthy foods from your current diet?

Anything else I may need to know please comment:

Please give me a typical day in what you eat and be as specific as you can. I would like you to give me what meal it is, the time, amount, anything you add to it, or other additional comments.

Additional nutrition info space:

Your Signature

Full Name

Today's Date

Hormone Consultation Intake Form

Please fill this out to the best of your ability.

Tell Me About You:

Lifting & Cardio

Health History

Females, please answer the following:

Nutrition

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