Intake Form

Please fill this out to the best of your ability.

It will be best and easiest to complete this extensive on a computer. You will need to attach starting pictures and cannot save the form to come back to it later

Today's Date

First Name

Last Name

Street Address

City

Postal / Zip code

Street Address Line 2

Region/State/Province

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 *** This just gives me a good idea to see how your body holds, your body type, etc. Please take a front, side, and back picture in good lighting with no shadows. Ladies- a swimsuit, sports bra/booty shorts are great Men-Compression shorts or briefs rolled up without a shirt.

Upload Front Image

Upload supported file (Max 15MB)

Upload Side Image

Upload supported file (Max 15MB)

Upload Back Image

Upload supported file (Max 15MB)

Lifting & Cardio

What time of day do you typicall work out? An if you workout morning, do you eat before?

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

What are your current "splits"? How many times a week, weights certain days or only upper or lower certain days, etc.

How many days have you lifted in the past month?

What is the duration of your workouts?

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

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 yes, explain when, what one(s), and why

What is your blood type?

Do you drink alcohol? If so, how many drinks/week? What kind of alcohol?

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 as well as brands. This includes vitamins, protein powders, fiber etc.

Explain to me your main issues you are having in relation to your system. Hormones, symptoms, digestive, mood, energy, etc.

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

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)

Have you taken antibiotics before? Frequently, every so often, when you were younger? When was the time, please explain your use the best you can.

Have you ever had any root canals? If so, how many and when?

Do you have any oral diagnosis or dental problems?

Do you have any metal fillings?

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

Do you ever have blood in stools? If so explain frequency

Do you have a bowl movement every day? If so, how many times?

Have you ever taken any PPI medicaiton? (acid reflux meds prescribed, or tums/rolaids often)

Do you suffer from any Anxiety, depression, OCD, ADD/ADHD, or any other mental health or neurological disorder?-please explain if yes

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

Upload File

Upload supported file (Max 15MB)

Nutrition/Lifestyle

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

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?

Have you ever had an eating disorder? If so, when and explain

How much water do you consume on average each day?

What kind of water do you drink? Tap water, distilled, filtered, RO. What kind of filter

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

What are your favorite healthy foods from your current diet?

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.

What kind of cookwear do you cook in? Stainless steel, ceramic, aluminum, etc

Do you have supportive friends and family with your health goals?

Do you have any access to a sauna?

Do you have any toxic relationships in your life?

Do you have a lot of stress in your life or worry a lot? Please explain.

Anything else I may need to know please comment:

By checking this box and signing this form, you know that Casie Shepherd Spectrum Wellness is not a doctor or licensed practitioner. Any testing and information given should not be taken as medical advice. Only a Licensed Medical Professional can diagnose and prescribe treatments and medications for you. Do not ignore or delay seeking medical advice or treatment because of any information obtained or recommended by Casie Shepherd Spectrum Wellness. Consult your own Medical Professional regarding all nutritional supplements to evaluate if the supplements could adversely affect or react with any medications or pre-existing conditions. Stop any food or supplement immediately if you have any type of adverse reaction. You agree that Casie Shepherd Spectrum Wellness and its representatives shall not be liable for damages arising from the information and recommendations given at anytime including any future or ongoing recommendations. You agree that this limitation of liability is comprehensive and applies to personal injuries and all damages of any kind, including without limitation direct, indirect, incidental, general, special, punitive, compensatory, and consequential damages. These tests are not intended to diagnose, treat, cure, or prevent any health problem - nor is it intended to replace the advice of a physician. Always consult your physician or qualified health professional on any matters regarding your health. By following any advice by Casie Shepherd of Spectrum Wellness, you agree that you do so at your own risk.

By checking this box I give permission for Casie Shepherd of Spectrum Wellness to use any results for marketing and research purposes but that personal and confidential information will be kept private unless otherwise given written consent.

Full Name

Your Signature

Today's Date

Intake Form

Please fill this out to the best of your ability.

It will be best and easiest to complete this extensive on a computer. You will need to attach starting pictures and cannot save the form to come back to it later

Tell Me About You:

Lifting & Cardio

Health History

Females, please answer the following:

Nutrition/Lifestyle

Home

Contact

Blog

Privacy Policy

About

Casie's Story

Before + After Gallery

Testimonials

Interviews

Services

Testing & Consulting

1 on 1 Coaching

Shop

NutriDyn

Full Script

Amazon

Intake Form

Please fill this out to the best of your ability.

**It will be best and easiest to complete this extensive on a computer. You will need to attach starting pictures and cannot save the form to come back to it later**

Tell Me About You:

Lifting & Cardio

Health History

Females, please answer the following:

Nutrition/Lifestyle

Blog

About

Services

It will be best and easiest to complete this extensive on a computer. You will need to attach starting pictures and cannot save the form to come back to it later