WellKids+
WellBundles
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WellKids+
WellBundles
Results
Nutrition & Lifestyle Intake Form – For a Personalized Assessment
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Personal Information
Name
*
First
Last
Date of Birth
*
DD
1
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MM
1
2
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YYYY
2027
2026
2025
2024
2023
2022
2021
2020
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1927
1926
1925
1924
1923
1922
1921
1920
Phone Number
*
Gender
Email Address
*
Medical History
Any diagnosed medical conditions?
Medications or supplement Being Taken
Recent lab tests or diagnoses?
Allergies
Past surgeries or major illnesses?
Lifestyle & Nutrition
What are your main health concerns or goals?
(e.g. weight loss, energy, digestion, hormonal balance)
Current Weight
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
Height
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
Weight Loss/Gain Goals
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
Food Preferences
Do you consume: Coffee/caffeine: ___ cups/day
Please provide how many cups per day, and which coffee type, with or without creamer...
Do you consume: Alcohol: ___ drinks/week
Please provide how many glass a week and which alcohol type ...
Water: ___ cups/day
Do you follow any dietary restrictions or preferences?
You may choose to provide this information only if you feel comfortable sharing it. It is entirely optional and will be kept strictly confidential.
Digestion & Elimination
How often do you have a bowel movement?
Daily
Every 2–3 days
Less often
Checkboxes
Bloating
Constipation or diarrhea
Fatigue
Brain fog
Irregular periods
Skin breakouts/rashes
Stress, Mood & Mental Load
How would you rate your stress level?
Low
Moderate
High
Do you practice stress management (e.g. meditation, yoga, breathwork)?
Yes
No
Occasionally depending on my free time
Do you experience any of the following on a regular basis?
Mood swings
Anxiety or overwhelm
Burnout
Low motivation
Emotional eating or cravings
Sleep Patterns
Do you use any sleep aids or supplements?
No
Yes
Do you use screens (phone, TV) within 1 hour of bed?
No
Yes
Do you have trouble falling asleep?
No
Yes
Do you have trouble staying asleep?
No
Yes
Do you have trouble waking up refreshed?
No
Yes
Average sleep duration per night:
<5 hrs
5–6 hrs
7–8 hrs
9+ hrs
Physical Activity & Movement
Do you engage in intentional physical activity or movement?
Yes
No
If yes, what type(s)?
(e.g., walking, yoga, weights, HIIT)
Frequency per week:
1x
2–3x
4+ times
Do you feel physically energized or fatigued after activity?
Yes
No
Do you have any movement limitations, joint pain, or injuries?
Yes
No
Women’s Health (if applicable)
Are you currently:
Pregnant
Breastfeeding
On hormonal birth control pills
On hormonal birth control IUD
None
Do you experience one of these symptoms?
Intolerable PMS (Migraine, brain fog, sad, stressed)
painful periods
cycle irregularities
None
Lifestyle Habits
Describe your typical daily schedule
(wake-up time, meals, work, downtime, bedtime)
Do you follow a consistent routine on weekdays and weekends?
yes
No
How often do you eat meals at the table?
Regularly
Occasionally
Rarely
How often do you eat meals on the go or while distracted (e.g., phone, driving)?
Frequently
Sometimes
Never
How often do you eat outside the home (restaurant, takeout, café)?
Rarely
1–2x/week
3–5x/week
Daily
What is your current occupation or daily role?
remote work
office work + commute
caregiver
shift work (night and day shift)
My role requires physical activity
None of the above
Food Relationship & Sugar Intake
trouble Physical role?
What are your comfort foods when feeling stressed, sad, or tired?
(e.g. soda, sweetened coffee/tea, energy drinks, juice) ___ drinks per week
How often do you eat processed or added-sugar foods?
Daily
A few times per week
Rarely
Do you crave sugar at a specific time of day?
Morning
Afternoon
Evening
After meals
I don't crave sugar
If yes, how do you typically respond?
Grocery Shopping & Food Choices
Do you usually shop with a grocery list or meal plan?
Yes
No
Sometimes
How do you feel while grocery shopping?
Confident and focused
Overwhelmed by choices
Impulsive with snacks/sweets
Pressed for time
How often do you buy items not planned or on your list (impulse purchases)?
Never
Sometimes
Often
Do you read food labels or nutrition facts when choosing products?
Yes
Sometimes
No
Nutrition Planning
Do you currently practice any form of nutrition planning?
Weekly meal planning
Batch cooking
Prepping snacks/lunches
No, but I’d like to learn
No, not currently
What’s your biggest challenge with planning or preparing meals?
Time
Ideas/creativity
Family preferences
Energy
Budget
Please feel free to share anything else you think we should know to better support you
Consent
*
I confirm that the information I’ve provided is accurate and understand that functional nutrition services are not a substitute for medical care. I consent to receiving personalized guidance from WellClinica.
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